Regency At Chene
Inspection history, citations, penalties and survey trends for this long-term care facility in Detroit, Michigan.
- Location
- 2295 E Vernor Highway, Detroit, Michigan 48207
- CMS Provider Number
- 235422
- Inspections on file
- 28
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Regency At Chene during CMS and state inspections, most recent first.
A cognitively intact resident with leukemia and pneumonia, assessed as not at risk for elopement and independent with ADLs, left the facility with family members without any LOA order, care plan, or documentation in the EHR. Staff, including an LPN and a CNA, assumed the resident was on an LOA based on informal comments, did not verify a physician order or sign-out information, and did not recognize or report the absence as a potential elopement until the end of the shift. The receptionist did not recall the resident leaving and did not have the resident identified in the elopement book, and existing signage instructing visitors to sign residents out was not effectively followed, resulting in the facility being unaware of the resident’s whereabouts.
The facility did not provide required information and access to the survey team in a timely manner, including the census, resident list, facility matrix, and WIFI access. Delays were attributed to staff unfamiliarity with the EMR system and incomplete access to clinical records, resulting in the survey team not receiving necessary documentation upon entry.
Several residents who required assistance with personal hygiene did not receive adequate care, including help with facial hair removal, showers, and nail care. One resident with multiple health conditions was observed with excessive facial hair and unclean nails, and reported not receiving scheduled showers due to inability to self-perform. Other residents were observed with long, dirty, or jagged fingernails, despite care plans indicating staff should provide this assistance. Documentation of care was incomplete, and relevant policies were not provided upon request.
Surveyors identified failures in medication storage and labeling, including expired and undated medications found on two medication carts, and unsecured medications left unattended on a cart by an LPN. The DON and unit manager confirmed these actions were not in accordance with facility policy. A resident involved was cognitively intact and recovering from knee surgery with multiple chronic conditions.
Staff were observed handling eating utensils without gloves and serving food with long, unrestrained hair, contrary to hygienic standards. Nursing staff participated in meal service without using required hair restraints, while dietary staff complied with these standards. The DON was unaware of the need for nursing staff to use hair restraints during meal service.
Staff did not consistently follow infection control protocols, including enhanced barrier precautions and proper use of PPE, for residents requiring such measures. In one case, a CNA handled soiled linen without a gown due to missing signage, and in another, a resident's PICC line was left uncovered and without a sterile cap. Additionally, a wound care nurse failed to perform hand hygiene between glove changes during wound care for two residents with complex medical needs.
Multiple residents were observed using wheelchairs with torn and ragged armrests, and several facility areas, including the walk-in freezer and nourishment rooms, had broken tiles, open holes, and unsanitary conditions. Kitchen equipment was found to be non-functional or leaking, and documentation regarding these issues was not provided to administration as requested.
A CNA took a photo of a resident's exposed buttocks with a personal cell phone after the resident expressed concerns about cleanliness following incontinence care. The photo was shown to the resident and an RN, leaving the resident feeling embarrassed, ashamed, and unsafe. The incident was not documented in the medical record, and facility policy prohibiting personal device use and resident photography was violated.
A resident with multiple medical conditions was found with their call light out of reach and hazardous items left at the bedside by family, without any care plan interventions or staff education to address these safety concerns. Staff acknowledged the issues but no documentation or care planning was in place to prevent recurrence.
A resident with end stage renal disease and an AV fistula did not have timely or complete physician orders for dialysis, clear fluid restriction parameters, or restrictions on blood pressure measurements on the arm with the fistula. Staff documented blood pressures on the affected arm and were unclear about the status of special instructions versus medical orders in the EMR, resulting in incomplete guidance for care.
A resident with cerebrovascular disease and vascular dementia was repeatedly observed being transported and seated in a wheelchair without footrests, resulting in poor posture and feet dangling. The resident reported that staff did not replace the footrests after removing them, and an Activities Assistant confirmed transporting the resident without footrests, contrary to facility policy and expectations.
Two residents did not receive pressure ulcer care as ordered by their physicians. In both cases, the wound care nurse failed to use the specified dressings and securement methods during wound care, despite clear orders and care plans. The nurse acknowledged not following the orders when questioned, and the facility's policy requires adherence to physician directives.
A resident with a history of stroke and moderate cognitive impairment was found to have long, thick toenails and dry, flaky skin due to a lack of timely foot care. Nursing staff confirmed the condition, and records showed the resident had not received podiatry services for approximately eight months, despite physician orders and facility policy requiring regular assessment and referral for such care.
A resident with hemiplegia and hemiparesis following a stroke did not receive prescribed splint application or ROM exercises, as staff failed to perform or document these interventions. The resident's splints were found unused, and interviews confirmed that CNAs were not completing the restorative program as ordered, with no documentation of care provided in the medical record.
A resident with impaired cognition and multiple medical conditions was left at risk for accidents due to inaccessible call lights, hazardous cleaning products at the bedside, and lack of staff intervention or family education regarding safety. Staff were aware of the issues but did not document or address them appropriately.
A resident with multiple chronic conditions and on hospice care was observed using an oxygen concentrator with a filter visibly covered in lint and dirt. Staff interviews revealed confusion about who was responsible for cleaning and maintaining the oxygen equipment, and the resident's care plan lacked interventions addressing equipment maintenance. Despite a contract with an outside company for oxygen equipment upkeep, the filter was not cleaned or replaced as required.
A medication cart was left unattended with an open EMR screen displaying a resident's PHI in a hallway, making confidential information visible to unauthorized individuals. An LPN confirmed leaving the cart unsecured, which was not in line with facility policy. The resident involved was recovering from knee surgery and was cognitively intact.
A resident with severe cognitive impairment and a history of acute cerebral vascular insufficiency and dysphagia did not receive routine dental services despite a physician order for evaluation and treatment. The care plan lacked documentation of dental concerns, and the MDS was incomplete for oral/dental status. Staff interviews revealed a lack of awareness and follow-through regarding the resident's dental needs, and dental notes were not available at the time of survey exit.
A resident with dysphagia and self-feeding difficulties was not provided with a physician-ordered scoop plate during meals, despite documentation and care plan requirements. Staff served meals on a regular plate and were unaware of the adaptive equipment order, while the necessary requisition for the scoop plate was not submitted, resulting in the resident not receiving the prescribed assistive device.
Two residents receiving hospice care did not have their comprehensive hospice documentation, including assessments and consents, accessible in their records as required. Nursing staff and management were unable to initially locate these documents, which were later found to be held by the administrator. Both residents had complex medical conditions and required significant assistance with daily activities. The DON acknowledged that hospice documentation should have been available to staff but could not account for its absence, resulting in a lack of coordinated hospice care.
A resident with multiple medical conditions and severe cognitive impairment did not receive the Pneumococcal and Influenza vaccines despite having signed consent forms. There was no documentation of vaccine administration in the medical record, and the facility could not provide the influenza vaccination policy when requested.
A resident admitted with acute pancreatitis and found to be cognitively intact did not receive a comprehensive MDS assessment within the required timeframe, with the assessment overdue by more than 120 days. The MDS nurse did not provide information about alerts for late assessments, and the DON indicated that policy should have been followed.
A resident with multiple chronic conditions did not receive any scheduled medications during an evening medication pass, and there was no documentation of administration or vital signs for that shift. Staff interviews confirmed the medications were not given, and the MAR was left blank, contrary to facility policy requiring proper administration and documentation.
A resident with multiple chronic conditions did not receive scheduled medications during an evening shift, and the MAR was left blank with no documentation from nursing staff. Facility staff, including the DON and an LPN, were unable to determine which nurse was assigned to the resident due to incomplete records and limitations in the electronic scheduling system.
A resident with a PEG tube did not receive the prescribed enteral feeding or water flush due to unlabeled and undated feeding and water bags, and an unprogrammed water flush rate. The resident's PEG tube insertion site was improperly cared for, with no dressing or abdominal binder applied. The facility's Enteral Nutrition policy was not followed, leading to this deficiency.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a wound and PEG tube. Staff provided care without wearing required gowns, and there was no signage or PPE supply cart available. The Director of Nursing acknowledged the lapse, despite staff being in-serviced on EBP. The resident's records indicated a physician's order for EBP, but the facility's policy was not followed, risking infection spread.
Two deficiencies were identified in respiratory care practices. The first involved a resident requiring mechanical ventilation who did not have an emergency tracheostomy readily accessible. During an observation, staff were unable to promptly locate a spare tracheostomy, leading to a delay in emergency care. The second deficiency was related to the failure to label and date oxygen tubing for a resident receiving oxygen therapy. The tubing was found to be unlabeled and undated, with the resident unable to recall the last change, posing a potential risk of respiratory infections.
The facility failed to maintain sanitary conditions in the kitchen, with soiled non-food contact surfaces and debris on equipment. Additionally, a meal test tray revealed improper food temperatures, with macaroni and cheese, collard greens, and fried chicken holding below the required 135 degrees F. These deficiencies could potentially affect 143 residents who receive meal services.
The facility failed to maintain the garbage storage area in a sanitary condition, with exterior trash dumpsters observed with open lids and surrounding trash and debris. Staff indicated this was a recurring issue after trash pickup. The facility's waste disposal policy and the 2017 U.S. Public Health Service Food Code were not adhered to.
The facility failed to ensure the 2nd floor wireless nurse call light system was effectively utilized by staff or had consistently functioning centralized monitor screens. A resident's bedside nurse call device was found frayed and taped over, and the nurse's station did not have an audible alarm. Further observations revealed that the computer monitors at various nurse's stations were either not displaying notifications or were turned off, leading to potential delays in response times and unmet resident care needs for 47 residents.
A resident was not dressed in their personal clothing, causing verbal frustration and impaired mental and psychosocial well-being. Despite reporting the issue to social services, no action was taken, and the resident's closet had limited clothing. The facility's policy mandates dressing residents in their desired clothing, but this was not followed.
The facility failed to ensure a call light was within reach for a resident with severe cognitive impairment and multiple medical conditions, and did not provide a wheelchair for another resident with a fractured hip. Both deficiencies resulted in unmet care needs, as confirmed by staff and multiple observations.
The facility failed to update PASARR forms for a resident with bipolar disorder and paranoid personality within the required 30-day period. The resident's MDS assessment indicated cognitive impairment and antipsychotic medication use. Staff interviews revealed that a new PASARR should have been completed 25 days after admission but was only done on the day of the survey. The DON confirmed that the Social Worker is responsible for PASARRs and that they should be reviewed on admission and sent for Level II evaluation if needed.
The facility failed to revise care plans in a timely manner for two residents, leading to deficiencies in their care. One resident's care plan did not address new wounds, and another resident's care plan was not updated after the removal of an indwelling catheter.
The facility failed to implement an appropriate discharge plan for a resident who had been in the facility for two months and expressed a desire to return home. Despite being alert and capable of making independent decisions, the resident was not receiving therapy and was left without a clear discharge plan. Staff interviews revealed a lack of communication and coordination regarding the resident's discharge.
The facility failed to provide adequate nail care, scheduled showers, and assistance with transfers out of bed for two residents. One resident had long, dirty fingernails despite being dependent on personal hygiene assistance, while another resident reported not being offered scheduled showers or assistance to get out of bed for three months, resulting in unkempt and greasy hair with a foul odor.
The facility failed to adequately assess and monitor wounds for a resident with a pertinent diagnosis of acquired absence of right and left leg above the knee. Despite the wounds being reported, there was no documentation of assessment, measurement, or monitoring, and no care plan was initiated, contrary to the facility's policy.
A resident was observed using broken reading glasses due to the facility's failure to provide vision services. Despite several requests to social services, the resident had not received assistance in obtaining new prescription glasses, which had been lost two years ago. The resident's medical record indicated intact cognition and a history of dementia, anxiety, and falls.
The facility failed to follow infection control standards during medication administration for a resident with Type 2 Diabetes. An LPN did not use a barrier for the glucometer, failed to clean it properly, and neglected hand hygiene, leading to potential cross-contamination risks.
Failure to Follow LOA Procedures Resulting in Unmonitored Resident Departure
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate supervision and follow its Leave of Absence (LOA) policy for a cognitively intact resident, resulting in the resident leaving the building with family without the facility’s knowledge of their whereabouts. The resident had been admitted with leukemia and pneumonia, had intact cognition per the MDS, and was independent with ADLs including ambulation. An elopement risk assessment completed prior to the incident indicated the resident was not at risk for elopement. However, there was no physician order, no care plan, and no documentation in the electronic health record authorizing or describing an LOA for this resident at the time they left the facility. On the evening in question, the resident was seen on the front door camera properly dressed and walking out of the facility with several family members at approximately 6:00 PM. The receptionist did not recall seeing anything unusual and did not remember seeing the resident leave, despite a sign at the exit instructing visitors to sign residents out when leaving. The facility did not have information on who the resident left with, where they were going, or how long they would be gone, and the resident was not listed in the receptionist’s elopement book. The resident did not return to the facility as expected, and the next morning it was reported in the morning meeting that the resident had not come back from what staff believed was an LOA. Staff interviews revealed that both nursing and CNA staff assumed the resident was on an LOA without verifying orders or documentation. An LPN stated that a CNA had told her the resident went on an LOA with family, but she did not check for an LOA order, did not confirm who the resident was with, and did not report the resident’s absence until the end of her shift. A CNA reported that when she went to pick up the resident’s dinner tray, the resident was not in the room and had earlier been with several visitors; she assumed the resident had gone somewhere with them and did not recognize the situation as a potential elopement, nor did she initiate an elopement response. The facility’s LOA policy required physician orders, care planning, sign-out/sign-in procedures, and implementation of elopement protocol if a resident left without the facility’s knowledge and whereabouts were unknown, but these procedures were not followed in this case.
Failure to Provide Timely Survey Information and Access
Penalty
Summary
The facility failed to provide timely and required information to the survey team upon entry and during the annual recertification survey, affecting all residents. Upon arrival, the survey team leader requested a facility census, resident list, and matrix from an RN, but these were not provided. Subsequent requests for the same information, as well as WIFI access, were made to the DON and NHA, with the full set of documents and access not provided until over an hour after entry. The WIFI access provided did not function throughout the survey, further impeding the process. The entrance conference worksheet, which outlines the required timeframes for document provision, was sent to the NHA, and the entrance conference was conducted, with the NHA confirming familiarity with the electronic file sharing platform. Delays continued as the NHA reported not having full access to the clinical portions of the EMR, and the DON was new and still acclimating to the system. Additional required documents, such as hospice agreements and dialysis contracts, were not provided within the required timeframe and had to be requested again. The DON later acknowledged that any unit manager should have been able to provide a census upon surveyor entry and agreed that the survey team was not provided timely documentation upon entry.
Failure to Provide Adequate Assistance with Personal Hygiene and Nail Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically in the areas of personal hygiene, for several residents who were unable to perform these tasks independently. One female resident was observed with excessive facial hair and dark matter under her fingernail, and reported not receiving scheduled showers due to pain from arthritis, which she could not manage without help. Documentation of her showers was incomplete or missing, and there was no record of her refusing care or assistance with facial hair removal. Her medical history included rheumatoid arthritis, dysphagia, diabetes with neuropathy, hypertension, acute kidney failure, and spinal stenosis, all of which contributed to her need for assistance with personal hygiene. Three other residents were observed with long, jagged, or dirty fingernails, and in some cases, debris under the nails. Interviews with staff and review of records confirmed that these residents required assistance with personal hygiene due to severe or moderate cognitive impairment, paraplegia, or hemiplegia following a stroke. The facility's care plans and Kardexes indicated that staff were to observe and trim nails on shower days, but observations and interviews revealed that this was not consistently done. There was no documentation in the electronic medical records of refusals of care for these residents. The Director of Nursing confirmed that CNAs were expected to check and provide nail care on shower days and during regular care, but this was not consistently documented or performed. Additionally, when requested, the facility was unable to provide the relevant policies for activities of daily living, shower, and nail care by the time of survey exit.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to medication management within the facility. During an inspection of two medication carts, expired and undated medications were found, including an expired vial of Humulin R insulin, an opened and undated vial of Lantus insulin, expired Vitamin E pills, and expired Fish Oil pills. When questioned, the registered nurse present was unable to provide an explanation for the presence of expired and undated medications. The Director of Nursing confirmed that staff are expected to follow facility policy, which requires medications to be dated and discarded per manufacturer guidelines. Additionally, a medication cart was found left unattended in a hallway with three prescribed medications unsecured on top of the cart. The LPN responsible admitted to leaving the cart and medications unattended while attending to a resident's vital signs. The unit manager and DON both confirmed that facility policy requires medication carts to be locked and that no medications should be left unattended or on top of the cart. The resident involved was cognitively intact and had a history of osteoarthritis, recent knee replacement, borderline diabetes, lipidemia, and hypertension.
Failure to Follow Hygienic Practices During Meal Service
Penalty
Summary
Surveyors observed that staff failed to follow hygienic practices during meal service, specifically in the handling and serving of food and utensils. Nursing staff were seen wrapping silverware in napkins and placing them on tables after washing their hands, but they touched the eating portions of the utensils without wearing gloves. Additionally, staff with long, loose hair were observed serving and assisting residents with food and beverages without using hair restraints, as required by professional standards and the 2013 Food Code. These practices were noted during multiple meal services in both the first and second-floor dining areas, involving approximately 30 residents at one time. The dietary manager confirmed that all dietary staff wore appropriate hair restraints, but the nursing staff, who also participated in meal service, did not. The Director of Nursing was unaware of the requirement for nursing staff to use hair restraints while assisting with meal service. The lack of proper glove use and hair restraints by nursing staff created the potential for food contamination during the observed meal services.
Failure to Follow Infection Control Protocols and Hand Hygiene Standards
Penalty
Summary
Staff failed to follow enhanced barrier precautions (EBP) and use appropriate personal protective equipment (PPE) for residents requiring infection control measures. In one instance, a certified nursing assistant (CNA) removed soiled linen from a resident on EBP without wearing a gown, as required. The CNA was unaware of the resident's EBP status due to the absence of a precautionary sign on the door. The infection control registered nurse later placed the sign, and interviews revealed that staff were expected to verify EBP status through the electronic medical record (EMR) or Kardex system. The resident involved had significant medical conditions, including end-stage renal disease and bacteremia, and a physician order for EBP was present in the EMR prior to the incident. The facility's EBP policy was requested but not provided at the time of the interview. Another deficiency was observed when a resident with a peripherally inserted central catheter (PICC) line was found in physical therapy with the line uncovered and lacking a sterile cap. The director of nursing (DON) acknowledged that the PICC line should have been covered with a sterile cap after each use, as outlined in the facility's policy for PICC line care. The policy specified that an end cap should be placed on the connector to reduce the risk of vascular-associated infections. The resident had a history of osteoarthritis, contracture, pain, and a surgical wound. Additionally, the facility failed to ensure proper hand hygiene during wound care for two residents. The wound care nurse was observed repeatedly removing gloves and donning new ones without performing hand hygiene between glove changes while providing wound care to residents with surgical wounds and pressure ulcers. The DON confirmed that staff would be re-educated on hand hygiene. The facility's hand hygiene policy emphasized the importance of hand washing to prevent healthcare-associated infections. The residents involved had complex medical histories, including recent surgeries, amputations, and pressure ulcers.
Failure to Maintain Safe and Sanitary Environment Due to Broken Equipment and Unsanitary Conditions
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by multiple observations of broken and unsanitary equipment and areas. Several residents were observed using wheelchairs with torn and ragged armrests, and one resident's wheelchair had uneven armrests. In the kitchen area, the walk-in freezer had approximately 5-6 missing floor tiles at the threshold, creating an indentation and a visible gap at the bottom of the freezer door, which led to ice accumulation and safety concerns. Delivery staff required assistance to move goods into the freezer due to the broken tiles. The Dietary Manager stated the threshold had been missing for over a year, and the Maintenance Manager indicated repairs were in process. Additionally, a double-deck steamer was non-functional, and a leaking faucet in the dish room caused water to overflow the sink. The nourishment rooms on both the first and second floors were found to be soiled and littered with paper and debris. The first-floor nourishment room had cracked floor tiles around the sink, creating an uneven surface, while the second-floor nourishment room had a 6x6 inch open hole in the wall, which was covered by a garbage can. The Dietary Manager reported that dietary staff monitored the nourishment rooms three times daily, but cleaning was the responsibility of housekeeping. Requested documentation regarding the broken equipment and safety concerns was not submitted to the Administrator by the time of the survey exit.
Violation of Resident Dignity and Privacy Due to Unauthorized Photograph
Penalty
Summary
A certified nurse assistant (CNA) failed to treat a resident with dignity and respect by taking a photograph of the resident's exposed buttocks using a personal cell phone. The incident occurred after the resident expressed concern about not feeling clean following incontinence care. The CNA, in response, took out their phone, asked the resident if they wanted to see a picture, and then took and showed the photo to the resident. The CNA also showed the photo to a registered nurse (RN) present at the time. The resident reported feeling embarrassed, ashamed, nervous, and scared as a result of this action. The resident involved had a history of multiple medical conditions, including hypertension, heart failure, diabetes, morbid obesity, asthma, peripheral vascular disease, epilepsy, obstructive sleep apnea, lymphedema, and anxiety. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. The care plan for the resident included interventions to encourage participation in self-care, provide positive reinforcement, and maintain a calm approach due to anxiety. Despite these interventions, the incident was not documented in the resident's medical record, and there was no evidence of psychosocial follow-up or documentation by staff regarding the resident's emotional state after the event. Facility policy explicitly prohibits the use of personal electronic devices, including cell phones, in resident care areas and strictly forbids taking photographs of residents. The CNA admitted to knowing that having a phone on the floor and taking pictures of residents was against policy. The lack of documentation and follow-up in the medical record, as well as the violation of privacy and dignity policies, contributed to the deficiency identified during the survey.
Failure to Develop and Implement Care Plan Interventions for Resident Safety
Penalty
Summary
The facility failed to develop and implement care plan interventions to monitor and prevent accidents for a resident, resulting in a potentially unsafe environment. During observations, the resident's call light was found on the floor and out of reach, and the resident was unaware of its location while expressing feeling unwell and requesting assistance. The bed was positioned at its highest height, further increasing the risk of accident. Staff acknowledged that the call light was out of reach after care had been provided, and it was noted that someone had just left the room without ensuring the call light was accessible. Additionally, hazardous items such as hydrogen peroxide and comet cleaner were found on the resident's bedside table on separate occasions. Staff indicated that the resident's family frequently brought in items and left them without informing staff, and there was no documentation of interventions, education, or care planning to address this ongoing behavior. The care plan did not include any measures to address the family's actions or to prevent unsafe items from being left with the resident, despite the resident's medical history of rheumatoid arthritis, dysphagia, lower back pain, diabetes mellitus with neuropathy, hypertension, acute kidney failure, and spinal stenosis.
Failure to Ensure Timely and Complete Dialysis Orders and Fluid Restriction Parameters
Penalty
Summary
A resident with end stage renal disease and dependency on dialysis was found to lack timely and complete physician orders for dialysis services. Observation revealed the resident had multiple cups of liquid and a large bottle of juice at the bedside, while the electronic medical record (EMR) did not contain a physician order for dialysis or clear directives regarding fluid restrictions. Additionally, there were no orders restricting staff from obtaining blood pressures on the resident's left arm, which contained an arteriovenous (AV) fistula used for dialysis. Documentation showed that blood pressures were recorded on the left arm on several occasions despite the presence of the AV fistula. Interviews with facility staff, including an LPN and the DON, confirmed the absence of a dialysis order in the medical orders section of the EMR and uncertainty about whether special instructions in the EMR qualified as medical orders. The facility's policy required a physician order for hemodialysis and monitoring of fluid restrictions for dialysis residents, but these requirements were not met for this resident. The lack of clear and accessible orders and directives created the potential for missed treatment, compromised vascular access, and inadequate fluid management.
Failure to Use Wheelchair Footrests During Resident Transport
Penalty
Summary
The facility failed to ensure that wheelchair footrests were in place during transportation and to assist with proper seated posture for a resident. On multiple occasions, the resident was observed sitting in a wheelchair without footrests, with her feet dangling and in a slouched position, both while stationary and while being transported by an Activities Assistant. The resident reported that staff often removed the footrests and did not replace them. The Activities Assistant acknowledged transporting the resident without footrests and stated that footrests should be used to prevent injury. Review of the resident's medical record indicated a history of cerebrovascular disease and vascular dementia, with moderate cognitive impairment and a need for dependent assistance with mobility. The Director of Nursing confirmed that footrests should be used during transportation and for positioning to ensure safety. Facility policy also stated that footrests should be down when the wheelchair is moving to prevent injury.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with physician orders and standards of clinical practice for two residents. For one resident with a left above-the-knee amputation and additional wounds on the right foot, the wound care nurse did not follow the physician's order for wound dressing. Specifically, the nurse used an ACE wrap instead of the ordered kerlix to secure the dressing on the right foot. The resident's care plan included interventions to follow facility protocols for impaired skin integrity, but these were not adhered to during observed wound care. For another resident with a history of a gunshot wound, paralysis, and an unstageable sacral pressure ulcer, the wound care nurse also failed to follow the physician's wound care order. The nurse did not secure the sacrococcyx wound with border gauze as ordered, instead applying only Maxorb AG and ABD dressing. Both incidents were observed directly, and the wound care nurse acknowledged not following the physician's orders when questioned. The facility's policy requires treatments to be rendered in accordance with specific physician orders, which was not done in these cases.
Failure to Provide Timely and Adequate Foot Care
Penalty
Summary
A deficiency was identified when a resident with a history of epilepsy, hemiplegia, and hemiparesis following a stroke was found to have long, thick toenails and dry, flaky skin on their feet. The resident, who had moderate cognitive impairment and required dependent assistance for personal hygiene, reported that their nails were not being adequately cared for. Observations by nursing staff confirmed the condition of the resident's feet, and it was noted that the resident had not seen a podiatrist for approximately eight months, despite having a physician's order for podiatry evaluation and treatment as indicated. Review of the resident's care plan indicated that staff were to observe finger and toenails on shower days to determine if trimming was needed, but there was no documentation of care refusals or evidence that this was being consistently done. The facility's policy required referrals to ancillary providers based on individualized needs, but the resident's last podiatry visit was significantly delayed. The deficiency was attributed to the facility's failure to provide timely and adequate foot care, including appropriate podiatry services, for the resident.
Failure to Provide and Document Required Splint Application and ROM Exercises
Penalty
Summary
A deficiency was identified when a resident with a history of epilepsy, hemiplegia, and hemiparesis following a stroke was not provided with the required application of splints and range of motion (ROM) exercises as ordered. Observations showed the resident in bed without the prescribed splints, and the splints were later found stored in a dresser drawer. The resident reported that staff were not applying the splints, stating that they were too busy. Interviews with a CNA and a registered nurse confirmed that splints were not being applied and ROM exercises were not being performed. The registered nurse indicated that CNAs were responsible for these tasks, but there was no restorative nurse or aides assigned to the program at that time. A review of the resident's electronic medical record revealed no documentation of splint application or ROM exercises, nor any record of refusals, for several weeks. The resident's care plan and Kardex included specific instructions for splint use and ROM exercises, but these interventions were not carried out or documented. The facility's policy required daily documentation of restorative care and interventions, but this was not followed for the resident in question.
Failure to Prevent Accident Hazards and Ensure Supervision
Penalty
Summary
A resident was found to be at risk for accidents due to multiple lapses in safety and supervision. On two separate occasions, the resident's call light was not within reach—once entangled in linens and another time on the floor—leaving the resident unable to summon assistance when feeling unwell. Additionally, the resident's bed was observed at its highest position, and the resident was unable to lower it independently. Staff acknowledged that the call light should always be accessible and that the resident required a Geri chair due to issues with the wheelchair armrests and risk of sliding out. Potentially hazardous products, including hydrogen peroxide and Comet household cleaner, were found at the resident's bedside. Staff indicated these items were likely left by the resident's family, who frequently brought in various items without notifying staff. There was no documentation of staff educating the family about safety or addressing the issue, and the unit manager was unaware of the situation. The resident had significant medical conditions, including impaired cognitive function, incontinence, and required assistance with activities of daily living.
Failure to Maintain Sanitary Oxygen Equipment for Resident
Penalty
Summary
The facility failed to ensure that respiratory equipment, specifically an oxygen concentrator and its components, was maintained in a sanitary manner for a resident receiving oxygen therapy. Observations revealed that the oxygen tubing was dated and changed, but the oxygen concentrator's filter was visibly covered with lint and dirt, which was confirmed by the surveyor upon inspection. Interviews with staff, including a hospice aide and a nurse, indicated confusion and lack of clarity regarding responsibility for the maintenance and cleaning of the oxygen equipment. The hospice aide stated she was only responsible for placing the oxygen back on the resident after care, while the nurse deferred responsibility to maintenance. The care plan for the resident did not include interventions related to the maintenance or cleaning of the oxygen equipment or its filter. The resident involved had multiple significant medical diagnoses, including atrial fibrillation, hypertensive heart disease with heart failure, type 2 diabetes mellitus, lymphedema, venous insufficiency, dementia, and acute respiratory failure with hypoxia. The resident was moderately cognitively impaired, frequently incontinent, and required extensive assistance with mobility and transfers. Despite a contract with an outside company to maintain oxygen equipment, the filter on the resident's oxygen concentrator was not cleaned or replaced as required, and there was no documentation or clear delegation of responsibility for this task in the resident's care plan or facility records.
Unsecured Medication Cart Exposes Resident PHI
Penalty
Summary
A medication cart on unit 300 was observed left unattended with the electronic medical record (EMR) screen open, displaying a resident's protected health information (PHI) in a hallway accessible to staff and residents. The cart was not secured, and the EMR was visible to unauthorized individuals. The LPN responsible for the cart confirmed leaving it unsecured with PHI visible, acknowledging this was not in compliance with facility protocol. The unit manager and Director of Nursing both confirmed that staff are expected to lock the cart and secure the EMR screen when not in use, as per facility policy. The resident whose PHI was exposed had been admitted for operative recovery from a total left knee replacement and had a history of borderline diabetes, lipidemia, and hypertension. The resident was cognitively intact at the time of the incident. Facility policies reviewed stated that residents' privacy must be safeguarded and that medication carts should be locked at all times when not in use or not within constant vision.
Failure to Provide Routine Dental Services for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide routine dental services to one resident with severe cognitive impairment and a history of acute cerebral vascular insufficiency and dysphagia. The resident was observed to be edentulous and unable to communicate about his oral health needs. Despite a physician order for a dental evaluation and treatment, there was no documentation in the care plan addressing dental concerns or the absence of teeth. The Minimum Data Set (MDS) for the resident did not have the oral/dental status completed. Interviews with facility staff revealed that the social worker was unaware of the resident's dental needs, even though a physician order was present. The DON acknowledged that the resident should have been seen by a dentist and confirmed that the social work department was responsible for arranging dental appointments. Dental notes for the resident were requested but not provided by the time of survey exit. Facility policy indicated that referrals to ancillary providers should be made based on identified needs, but this process was not followed for the resident in question.
Failure to Provide Prescribed Adaptive Eating Equipment
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, obesity, and self-feeding difficulties was not provided with the prescribed adaptive eating equipment, specifically a scoop plate, as ordered by the physician and indicated on the care plan. The resident was observed being fed by staff using a regular plate instead of the adaptive equipment, despite the tray card and physician order specifying the need for a scoop plate. Staff interviews revealed a lack of awareness regarding the therapy recommendations and the physician's order for the scoop plate. The dietary aide confirmed that the resident previously received meals with a scoop plate, but the new order on the tray card was not matched with the actual provision of the equipment due to the absence of a requisition for purchase. Further review showed that the registered dietitian was unaware of the order and discovered that therapy had not submitted the necessary requisition to obtain the scoop plate. The facility's policy required adaptive equipment to be provided based on comprehensive assessment, but this process was not followed, resulting in the resident not receiving the prescribed adaptive device. The resident's medical record indicated multiple diagnoses, including acute respiratory failure, dysphagia, and muscle weakness, and the MDS assessment showed moderate cognitive impairment and a need for one-person assistance with ADLs.
Failure to Maintain Accessible Hospice Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that relevant hospice documentation was accessible for two residents who were receiving hospice services. For one resident, the nurse was unable to locate the comprehensive assessment, consent for hospice benefits, or the hospice comprehensive plan of care in the designated Hospice Notebook. The unit manager and social worker were also initially unaware of the location of these documents, and it was later revealed that the administrator had them. The documents showed that the resident had been admitted to hospice, but there was a possible lapse in service as indicated by the dates on the comprehensive assessment benefit period. The resident had multiple diagnoses, including atrial fibrillation, heart failure, diabetes, lymphedema, venous insufficiency, dementia, and acute respiratory failure, and required extensive assistance with daily activities. For the second resident, the hospice comprehensive assessment was not included in the electronic health record until a later date, despite the resident being admitted to hospice care earlier. This resident also had significant medical conditions, including acute cystitis, dysphagia, severe malnutrition, pressure ulcer, vascular dementia, aphasia, and major depression, and required maximal assistance for most activities of daily living. The Director of Nursing confirmed that the hospice documentation should have been accessible in the residents' records but was unable to explain why it was missing. The lack of accessible hospice documentation resulted in a lack of coordination of comprehensive services and care for both residents.
Failure to Administer and Document Pneumococcal and Influenza Vaccines
Penalty
Summary
The facility failed to administer both the Pneumococcal and Influenza vaccines to one resident, despite having obtained signed consent for these vaccinations. Documentation provided by the Infection Control RN confirmed that the resident had signed to receive both vaccines, but there was no evidence in either the vaccination book or the electronic medical record that the vaccines were actually administered. The Director of Nursing acknowledged the absence of documentation for vaccine administration, even though the expectation was that residents who sign consent forms would receive the vaccines. The resident involved had multiple significant medical conditions, including a history of stroke, chronic obstructive pulmonary disease, hypertension, generalized anxiety, major depressive disorder, dysphagia, and aphasia. The resident was also noted to be severely cognitively impaired. Facility policy required documentation of vaccine administration, including the injection site, in the medical record, but this was not completed. Additionally, the facility was unable to provide the influenza vaccination policy when requested during the survey.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment in a timely manner for one resident who was admitted with a diagnosis of acute pancreatitis and was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15/15. Review of the resident's electronic medical record showed that the MDS assessment was overdue by more than 120 days. During interviews, the MDS nurse did not respond when asked about receiving alerts for late assessments, and the DON stated that the MDS nurse should follow the facility's policy for MDS assessments.
Failure to Administer and Document Scheduled Medications
Penalty
Summary
A deficiency occurred when a resident did not receive any of their scheduled medications during an evening medication pass. The resident, who had diagnoses including hypertension, heart disease, and diabetes, reported not receiving their medications, which included insulin and a blood pressure pill, on the specified evening. Review of the Medication Administration Record (MAR) confirmed that none of the medications scheduled for that time were signed out, and there was no documentation of vital signs or blood sugar checks for that shift. The resident's subsequent vital signs and blood sugar were within normal limits the following morning, but the lack of medication administration and documentation was evident for the evening in question. Interviews with facility staff, including the LPN and DON, revealed that neither could initially determine who was assigned to the resident during the shift, and the MAR remained blank for all scheduled medications. The LPN later identified as assigned to the resident stated they did not recall working that assignment and confirmed that if the MAR was blank, the medications were not given. The facility's policy requires medications to be administered according to physician orders and documented on the MAR, which was not followed in this instance.
Incomplete Medical Records and Unclear Nurse Assignment for Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident reviewed for medication administration. On the evening of February 6th, the resident did not receive any of their scheduled medications, and the Medication Administration Record (MAR) for that shift was left blank with no signatures or documentation from nursing staff. The resident, who had diagnoses including hypertension, heart disease, and diabetes, reported not receiving medications and was unable to identify the nurse assigned to them that evening. The resident's electronic health record also lacked progress notes, vital signs, and blood sugar results for the relevant shift. Upon review, facility staff, including an LPN, nurse manager, and the Director of Nursing (DON), were unable to determine which nurse was assigned to the resident during the shift in question. The facility's electronic scheduling system only indicated which nurses were scheduled and clocked in, but did not specify unit assignments. The nurse identified as possibly assigned to the resident could not recall working with the resident or on that unit and stated that if the MAR was blank, the medications were not administered. The Nursing Home Administrator and DON confirmed there was no accurate way to determine the nurse assignment for that shift due to lack of documentation.
Failure to Provide Appropriate PEG Tube Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a PEG tube, resulting in the resident not receiving the prescribed amount of enteral feeding or water. During an observation, it was noted that the tube feeding bag was unlabeled and undated, with no indication of when it was hung. The water flush bag was also unlabeled and full, indicating that the resident did not receive any water flushes. The infusion pump showed that the tube feeding rate was set at 75 ml/hr, but the water flush rate was not programmed, resulting in a rate of 0 ml/hr. Licensed Practical Nurse (LPN) B acknowledged the error, stating that the water flush was not programmed, and the resident did not receive any water the previous night. Additionally, the resident's PEG tube port had broken, requiring a hospital visit for a new tube insertion. However, LPN B could not provide details on when the tube feeding and water were restarted or how much the resident received. The infusion pump indicated that only 705 ml of tube feeding had been infused, with no start date or time available. The resident's PEG tube insertion site was found open to air with a small amount of reddish drainage, and the required 4 x 4 split gauze was not properly adhered. The abdominal binder, ordered for PEG tube securement, was also not applied. The Director of Nursing (DON) confirmed the resident did not receive the prescribed enteral feeding or water flush and acknowledged the lack of labeling on the feeding and water bags. The facility's Enteral Nutrition policy requires labeling and specific orders for enteral feeding, which were not followed in this case.
Inadequate Infection Control Practices for Resident with Wound and PEG Tube
Penalty
Summary
The facility failed to ensure appropriate infection control practices related to Enhanced Barrier Precautions (EBP) for a resident with a wound and PEG tube. During an observation, the resident was found lying in bed with visibly soiled clothing and a soiled gauze dressing in the bed. Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA) entered the room to provide incontinence care without wearing gowns, which are required under EBP for residents with wounds and indwelling medical devices. The staff acknowledged the need for gowns but had to leave the room to obtain them, as there was no signage or PPE supply cart available in or near the resident's room. The Director of Nursing (DON) confirmed the lapse in following EBP, noting that the staff had been in-serviced on the precautions but failed to implement them correctly. The resident's electronic health record indicated a physician's order for EBP due to the presence of a PEG tube and wound. The facility's policy mandates the use of EBP for residents with wounds or indwelling medical devices, requiring signage and readily available PPE. However, these measures were not in place, leading to the potential for the spread of infection.
Deficiencies in Respiratory Care: Emergency Tracheostomy and Oxygen Tubing Management
Penalty
Summary
The facility was cited for two deficient practices related to respiratory care. The first deficiency involved the failure to ensure an emergency tracheostomy was readily accessible for a resident (R138) who required mechanical ventilation. During an observation, it was noted that R138 did not have an emergency trach visible in their room, and staff members were unable to locate one promptly. Despite R138's history of respiratory failure and the need for a tracheostomy, there was no spare tracheostomy at the bedside, leading to a delay in accessing emergency care when needed. The second deficiency identified was the failure to label and date oxygen tubing for a resident (R48) receiving oxygen therapy. The observation revealed that R48's oxygen tubing connected to the concentrator was unlabeled and undated, with the resident unable to recall the last time the tubing was changed. Staff members acknowledged the importance of labeling and dating oxygen tubing to track usage and ensure cleanliness, highlighting the potential risk of respiratory infections associated with unclean tubing.
Sanitary Conditions and Food Temperature Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which resulted in an increased potential for cross-contamination of food and foodborne illness. Observations revealed soiled non-food contact surfaces, including ventilation filters above the fryer, the top and sides of the fryer, the sides of the oven next to the fryer, the grates of the flat top grill, and the six-burner oven's stainless steel backsplash. Additionally, the number ten can opener's cutting blade at the cook prep station was observed with visible debris and metal shavings. The flooring throughout all the facility's nourishment rooms was also found to have an accumulation of dust and debris. The Dietary Director acknowledged that these areas were not being cleaned sufficiently and timely, despite the kitchen's cleaning policy stating that these areas should be cleaned three times a day after each meal. No additional cleaning schedule documenting verification of the daily cleaning tasks was provided for review. The facility also failed to maintain proper food temperatures during meal service. A meal test tray revealed that the macaroni and cheese and collard greens were holding at a temperature of 105 degrees F, and the fried chicken at 100 degrees F, which is below the required 135 degrees F for hot holding. The Dietary Director and staff acknowledged the issue and mentioned the need for additional insulated meal carts and a functioning plate warmer to prevent meals from sitting too long before being served. This failure to maintain proper food temperatures could potentially affect 143 residents who receive meal services.
Improper Garbage Disposal and Sanitation
Penalty
Summary
The facility failed to ensure that the garbage storage area was maintained in a sanitary condition, which increased the potential for the harborage and feeding of pests. During a tour of the facility, the surveyor observed exterior trash dumpsters with lids in the open position and a variety of trash, debris, and used fryer oil surrounding the area. Staff E mentioned that the area often looks like this after trash pickup, and the doors are left open. The facility's waste disposal policy, dated April 2015, stated that outside dumpsters should be maintained in a clean manner, not overflowing, and with lids closed at all times. This was not adhered to, as observed by the surveyor. The 2017 U.S. Public Health Service Food Code also directs that receptacles and waste handling units should be kept covered with tight-fitting lids or doors if kept outside the food establishment, which was not followed in this instance.
Inconsistent Functioning of Nurse Call System
Penalty
Summary
The facility failed to ensure the 2nd floor wireless nurse call light system was effectively utilized by staff or had consistently functioning centralized monitor screens. During an environmental tour, a resident's bedside nurse call device was found frayed and taped over, and upon testing, it was observed that the nurse's station did not have an audible alarm, although the call light was flashing on a computer monitor. A Registered Nurse admitted that the sound was turned off because it was always going off. The Maintenance Director was unaware of the issue and mentioned that the system alarms at each nurse's station on the computer screen and through speakers, but no wireless pagers were used to notify staff of resident needs. Further observations revealed that the computer monitors at the 800, 500, and 600 hall's nurse's stations were either not displaying notifications or were turned off. The Maintenance Director had to reset and reattach cords to the monitors to get them functioning again. Additionally, a Registered Nurse expressed a preference for keeping the monitor off. Bells were available for use on each resident floor as an alternative notification method, but the primary nurse call system was not consistently operational, leading to potential delays in response times and unmet resident care needs for 47 residents.
Failure to Maintain Resident Dignity by Not Providing Personal Clothing
Penalty
Summary
The facility failed to maintain the dignity of a resident (R16) by not dressing them in their personal clothing. On multiple occasions, R16 was observed wearing clothes that did not belong to them, which caused the resident verbal frustration and impaired their mental and psychosocial well-being. R16 reported that their personal clothes had been missing for about two weeks, and despite informing social services, no action was taken. The resident's closet was observed to have limited clothing, and the assigned CNA confirmed that they had to dress R16 in miscellaneous clothes from the laundry that belonged to other residents. R16 was admitted to the facility with diagnoses including dementia, diabetes mellitus type two, malignant neoplasm of the stomach, and major depressive disorder. The resident was cognitively intact with a BIMS score of 14/15 and required extensive assistance with ADLs, including dressing. The facility's policy on Resident Dignity & Personal Privacy mandates that residents should be dressed in their desired clothing, but this was not adhered to in R16's case. The DON confirmed that it should take only one day to wash and return residents' clothes, indicating a failure in the facility's processes.
Failure to Provide Call Light and Wheelchair
Penalty
Summary
The facility failed to ensure a call light was within reach for one resident (R43) and a wheelchair was provided for another resident (R108), resulting in unmet care needs. R43, who has severe cognitive impairment and multiple medical conditions including dysphagia, chronic obstructive pulmonary disease, and hemiplegia, was observed lying in bed without a call light within reach. R43 expressed discomfort and the need for assistance to be repositioned. The facility's policy and R43's care plan both indicated that call lights should be within reach to ensure safety and assistance, but this was not adhered to, as confirmed by the LPN and the Director of Nursing (DON). R108, who was admitted with a fractured hip and no cognitive impairment, reported not having a wheelchair to get up. Multiple observations confirmed the absence of a wheelchair in R108's room. The Therapy Manager and the DON both acknowledged that it is the facility's responsibility to provide necessary mobility aids such as wheelchairs and walkers. Despite this, R108 was left without a wheelchair, which is essential for mobility and emergency situations. These deficiencies highlight the facility's failure to accommodate the needs and preferences of its residents as required by their policies and care plans.
Failure to Update PASARR Forms for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Annual Resident Review (PASARR) forms were reviewed, revised, and sent to the local state agency for evaluation of intellectual or developmental disability needs for one resident. The resident was admitted with diagnoses including bipolar disorder and paranoid personality, but the PASARR Level I screen from the hospital was not updated within the required 30-day period. The resident's Minimum Data Set (MDS) assessment indicated cognitive impairment and the use of antipsychotic medication. Interviews with facility staff revealed that a new PASARR should have been completed 25 days after admission, but it was only completed on the day of the survey. The Director of Nursing confirmed that the Social Worker is responsible for completing PASARRs and that they should be reviewed on admission and sent for Level II evaluation if needed.
Failure to Revise Care Plans in a Timely Manner
Penalty
Summary
The facility failed to revise care plans in a timely manner for two residents, leading to deficiencies in their care. Resident R18, who had bilateral above-the-knee amputations and two open wounds on the bottom back side of the right leg, did not have an updated care plan addressing these wounds. The care plan still included outdated interventions for previous conditions and had not been revised to reflect the current state of the resident's health. The Director of Nursing confirmed that the care plans should have been updated to include the new wounds and that the previous interventions should not have been documented as active. Resident R121, who was admitted with an indwelling catheter, had the catheter removed in March, but the care plan was not updated to reflect this change. The care plan still indicated the presence of the catheter, despite physician orders to discontinue it. The facility's policy on care planning requires that care plans be developed, reviewed, and revised based on comprehensive assessments, but this was not followed in the cases of R18 and R121.
Failure to Implement Appropriate Discharge Plan
Penalty
Summary
The facility failed to implement an appropriate discharge plan for a resident (R79) who had been in the facility for two months and expressed a desire to return home. Despite being alert, oriented, and capable of making independent decisions, the resident was not receiving therapy and was left without a clear discharge plan. The resident's clinical record indicated a goal to return to the community, but no active discharge planning was documented. Progress notes showed initial discussions about discharge plans, but no follow-up actions were taken, and no physician orders for discharge were present in the medical record. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's discharge. The Therapy Manager was unaware of why the resident had not been discharged, and the Social Worker was not informed of the resident's desire to leave until the day of the interview. The facility's policy on discharge planning, which mandates that discharge planning should start at the time of admission, was not followed, resulting in the resident's prolonged stay and unmet needs.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate nail care, scheduled showers, and assistance with transfers out of bed for two residents. Resident R100 was observed with long fingernails and debris underneath, despite being dependent on personal hygiene assistance. There was no documentation indicating that R100 preferred long nails or had refused nail care. Observations over multiple days confirmed that R100's nails remained untrimmed and dirty. The Assistant Director of Nursing confirmed that residents' nails should be cleaned and trimmed unless otherwise preferred by the resident, which was not the case for R100. Resident R13 reported not being offered scheduled showers or assistance to get out of bed for the past three months. Observations revealed R13's hair was unkempt, greasy, and had a foul odor, with a knot that required cutting out. The resident's care plan indicated a need for assistance with various ADLs, including bathing and transfers, but there was no documentation of noncompliance with scheduled showers or getting out of bed. A review of the scheduled shower task showed missed opportunities for showers, marked as not applicable. The Director of Nursing confirmed that residents should be offered showers first and that refusals should be documented and care planned, which was not done in R13's case.
Failure to Adequately Assess and Monitor Wounds
Penalty
Summary
The facility failed to provide adequate assessment and monitoring of wounds for one resident (R18) out of three residents reviewed for wound care management. During an observation and interview, it was noted that R18 had two open wounds on the bottom back side of the right leg. The wounds were first reported on 4/7/24, but there was no documentation of assessment, measurement, or monitoring of the wounds after that date. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the wounds were not measured or documented as required by the facility's policy. The resident, who had a pertinent diagnosis of acquired absence of right and left leg above the knee and required substantial assistance with Activities of Daily Living (ADLs), did not have a care plan initiated for the wounds. The facility's policy on skin management mandates that new areas of skin impairment should be reported and assessed promptly, with weekly evaluations until resolved. However, this protocol was not followed, leading to a deficiency in wound care management for R18.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to provide vision services for a resident, resulting in inadequate eyewear. During an observation and interview, the resident was seen wearing broken reading glasses held together with tape. The resident reported that the prescription glasses had been lost about two years ago and that several requests had been made to social services for assistance in obtaining new glasses. The resident's electronic medical record indicated a history of dementia, anxiety, and falls, with intact cognition as per the latest Minimum Data Set (MDS) assessment. Social services staff confirmed that they were unaware of the resident's need for new glasses and stated that the resident would be scheduled to see an optometrist in the future. The Director of Nursing confirmed that it was the responsibility of the social services department to assist residents with such ancillary needs. The lack of timely assistance resulted in the resident using inadequate eyewear for an extended period.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to adhere to infection control standards during the administration of medication to a resident diagnosed with Type 2 Diabetes. An LPN entered the resident's room with blood glucose supplies in hand and placed the glucometer on the resident's bed without using a barrier. After performing the blood glucose test, the LPN did not clean the glucometer, did not perform hand hygiene, and placed the used glucometer back in the medication cart. The LPN acknowledged the failure to clean the glucometer properly and admitted to using an alcohol swab instead of the required disinfectant wipe. The Director of Nursing confirmed that the glucometer should be cleaned with a disinfectant wipe after each use and that alcohol wipes are not acceptable. The facility's policies on glucometer decontamination and hand washing were reviewed, indicating that the glucometer should be placed on a clean surface, cleaned with a disinfectant wipe, and hand hygiene should be performed after glove use. The LPN's actions were inconsistent with these policies, leading to a potential risk of cross-contamination and infection among residents.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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