Regency At Fremont
Inspection history, citations, penalties and survey trends for this long-term care facility in Fremont, Michigan.
- Location
- 4554 West 48th Street, Fremont, Michigan 49412
- CMS Provider Number
- 235176
- Inspections on file
- 24
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Regency At Fremont during CMS and state inspections, most recent first.
A resident with prior pelvic and sacral fractures and Parkinson’s disease experienced an unreported fall while receiving care, after which she developed severe pain, a large right hip and low-back bruise, new sciatica, increased confusion, and marked declines in mobility and continence. CNAs and nurses noted bruising, confusion, hallucinations, pain, and the need for two-person sit-to-stand assistance, and the resident was sent to the ED for confusion, where hospital staff documented a possible fall, but the facility did not obtain the full hospital record, did not complete timely comprehensive assessments, and did not initiate a fall investigation or promptly notify the provider or management. Over several days, documentation showed increased urinary and new bowel incontinence, functional decline, and a downward hemoglobin trend, yet these were not recognized or reported as significant changes in condition. When the resident was finally transferred back to the hospital, imaging revealed multiple new and worsened pelvic and sacral fractures, spinopelvic dissociation, a large buttock hematoma, and cauda equina on presentation, while the facility’s records lacked timely incident reporting and change-in-condition response as required by its fall management policy and nursing standards.
The facility did not adhere to professional standards for medication and treatment administration, including discrepancies in controlled drug documentation, failure to follow physician-ordered parameters for medication administration, missing or inaccurate weight documentation for a resident with CHF, lack of timely fentanyl patch changes, and incomplete documentation of treatments on two units. These deficiencies were identified through observation, record review, and staff interviews.
Surveyors found multiple deficiencies in food storage, dating, and sanitation, including expired and undated food items, unsanitary equipment such as ice machines and microwaves with visible debris, and the use of damaged utensils. Ice chest coolers were also improperly maintained, with water accumulating among the ice. These failures were observed during interviews and inspections with the Certified Dietary Manager.
Surveyors found that several residents with physical and cognitive impairments did not have call lights within reach as required by their care plans and facility policy. Additionally, a resident with complex disabilities experienced ongoing pain and discomfort due to the facility's failure to provide a properly fitted wheelchair, despite repeated grievances and guidance from the Ombudsman and family. Staff were aware of these issues, but necessary assessments and documentation for DME were not completed, and grievances remained unresolved.
The facility did not effectively address or document grievances raised by the Resident Council, particularly regarding delayed call light response and slow meal service. Residents reported that their concerns were repeatedly brought up in meetings without follow-up or resolution, and documentation failed to reflect these ongoing issues. Observations confirmed significant delays in meal service, and the Nursing Home Administrator was unaware of the residents' concerns.
The facility did not accurately document or ensure the administration of controlled medications according to provider orders for four residents. Controlled substances were dispensed without active orders, and there was missing documentation of administration on required records, contrary to facility policy.
Staff transported multiple cognitively impaired residents with significant mobility issues in wheelchairs without using footrests, resulting in residents' feet dragging on the floor during movement. This occurred despite facility policy requiring the use of footrests for safety, as confirmed by an LPN.
Two residents experienced undignified care due to delayed or inadequate response to call lights, resulting in incontinence and emotional distress, while a Spanish-speaking resident was not provided with a communication care plan or consistent translation services, limiting her ability to participate in care decisions.
A resident with severe cognitive impairment and total dependence on staff was observed sitting in a public area with visibly wet pants from urine for an extended period. Staff did not promptly address the incontinence, resulting in the resident remaining in soiled clothing until he was eventually taken for a change and peri-care, failing to uphold the resident's dignity.
A resident who regularly received hemodialysis was not accurately documented as receiving dialysis on multiple MDS assessments. The MDS Coordinator/RN confirmed that the omission occurred, resulting in inaccurate assessment records for the resident's special treatments.
A Spanish-speaking resident with bilateral leg amputations did not have a communication care plan in place, resulting in staff and medical providers being unable to effectively communicate with her about her care and incidents such as a fall. The facility did not ensure translation services or Spanish-speaking staff were consistently used, and leadership confirmed the absence of a care plan addressing her communication needs.
A resident with chronic respiratory conditions and a history of multiple hospitalizations did not receive comprehensive nursing or provider assessments following readmission. Despite care plan instructions and acute changes in condition, staff failed to consistently monitor vital signs, document respiratory assessments, or notify the provider of significant changes, resulting in a lack of timely intervention.
A resident who was admitted without pressure ulcers and assessed as low risk developed a new stage II pressure ulcer on the left heel during their stay. Facility staff failed to update the care plan with new interventions after the ulcer developed, and documentation about the wound was inconsistent. Observations showed improper positioning that was not addressed in the care plan, and staff interviews revealed confusion about the wound's status and history.
A resident with moderate cognitive impairment continued to receive as-needed Lorazepam beyond the recommended 14-day limit, despite a pharmacy recommendation and physician acceptance to limit the duration or provide clinical justification. The order lacked a stop date and required documentation, and the pharmacy's recommendation was not acted upon.
Staff failed to follow infection control protocols during wound care, peri-care, and blood glucose monitoring for three residents. An LPN did not perform hand hygiene between glove changes and allowed wound packing gauze to touch unclean surfaces. A CNA performed peri-care in an incorrect sequence and did not clean a chair contaminated with urine. Additionally, an LPN conducted a blood glucose test in a communal dining area without ensuring privacy, contrary to facility policy.
The facility did not conduct fire drills at unexpected times or under varying conditions, instead holding drills at similar times during each shift. This lack of variation was confirmed by review of drill records and interview with the Maintenance Director.
The facility did not document the required monthly battery test for its generators, omitting checks for specific gravity fluids or cold crank amperage as mandated by NFPA 110. This deficiency was identified during a record review and confirmed by the Maintenance Director, affecting the facility's ability to verify generator readiness during power loss.
A kitchen hood filter system above commercial cooking appliances was found with a filter partially out of position, resting on top of another filter and not maintaining a proper seal. This issue was confirmed by the Maintenance Director during the survey.
A deficiency was found when a power strip was observed plugged into another power strip at the staff desk in the physical therapy area, supplying power to several items. This setup did not comply with NFPA 99 and NFPA 70 standards for electrical safety, as confirmed by the facility Maintenance director.
The facility did not update its facility-wide assessment to reflect the current census of 93 residents, as it was based on an outdated profile with an average daily census of 73. The Core Staffing and Personnel Audit had not been reviewed since August 2024, and the roles of the NHA and DON were not updated. The NHA, in the role for 90 days, was unaware of the need for this update.
A resident with severe cognitive impairment and a history of inappropriate sexual behavior was not adequately supervised, leading to a sexual abuse incident involving another cognitively impaired resident. Despite care plan interventions requiring direct supervision and 15-minute checks, staff were unaware of the resident's whereabouts, resulting in a failure to prevent the incident.
A resident with hypertension and Torsades de Pointes received blood pressure medications without proper monitoring, as required by physician orders. The facility's MARs showed multiple instances where medications were administered despite blood pressure readings being below the specified threshold or not obtained at all. The Nursing Home Administrator confirmed the oversight, noting the removal of blood pressure documentation boxes from the MARs by the pharmacy.
A resident with severe intellectual disabilities and other conditions was verbally and physically abused by a CNA during care. The CNA used derogatory language and placed her hand over the resident's mouth, which was witnessed by a CNAT. The facility's policy prohibits such abuse, and the incident was reported to the State Licensing Board.
The facility failed to ensure proper labeling and dating of foods and documentation of food temperatures, affecting 70 residents. Unlabeled and undated food items were found in the kitchen, and temperature logs for certain meals were incomplete. The Dietary Manager confirmed these oversights, which violated both FDA guidelines and the facility's policies.
The facility failed to maintain outdoor dumpsters, affecting 70 residents. Observations revealed that the lids of two dumpsters were not closed, with the trash dumpster lid stuck due to a bent frame. The Maintenance Director was unaware of the issue until informed and later fixed the lid. The Nursing Home Administrator admitted there was no policy regarding the dumpsters.
The facility failed to report and investigate allegations of sexual abuse involving three residents with dementia. Incidents included inappropriate touching and sexually explicit comments, but were not reported to the State Agency or properly investigated, resulting in a deficiency in resident safety.
The facility failed to protect residents and investigate allegations of abuse involving three residents with severe cognitive impairments. Incidents of inappropriate sexual behavior were not reported or investigated properly, and staff were inadequately trained and staffed to handle such situations.
The facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and a stage 3 pressure ulcer, resulting in inconsistent use of required heel protection boots and potential for impaired wound healing.
The facility failed to maintain sufficient nursing staff, resulting in incidents involving inappropriate behaviors and potential abuse among residents with severe cognitive impairments. Despite being on 15-minute checks, a male resident was able to inappropriately touch a female resident, and another male resident was found inappropriately touching himself in the presence of the same female resident. These incidents were not properly reported or investigated, highlighting significant staffing and procedural deficiencies.
The facility failed to ensure opened medications were labeled and expired medications were disposed of, as observed in two medication carts. An insulin pen, an inhaler, and eye drops were found without open dates, leading to their disposal due to potential expiration concerns. The facility's policy on labeling and checking expiration dates was not consistently followed.
Failure to Recognize and Respond to Resident’s Post-Fall Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to promptly identify and act upon a resident’s change in condition following an alleged fall, resulting in delayed medical treatment for significant pelvic and sacral fractures. The resident was an older female admitted with existing sacral and pelvic fractures from a prior fall and Parkinson’s disease, and was cognitively intact with a BIMS score of 13. Her Kardex indicated she required one-person assist with a gait belt and walker for stand-pivot transfers and that staff were to report changes in normal behavior and decline in ADLs and continence. On the date of the alleged incident, a family member later reported that the resident told him she fell in the shower and that the aide told her not to tell anyone. The family member identified the aide as a specific CNA, who denied involvement or knowledge of a fall. There was no documentation in the EMR that this CNA notified licensed staff or management of a fall allegation on that date. Over the next several days, multiple changes in the resident’s condition occurred without appropriate assessment, documentation, or escalation. The family member observed that the resident had increased pain over the weekend and later increased confusion. A CNA reported finding a large bruise on the resident’s hip and stated she immediately notified an RN, but there was no documentation of a physical assessment, investigation, or notification of the provider or family regarding this new injury. Nursing notes documented confusion with hallucinations, pain to both lower extremities that improved with repositioning, and elevated blood pressure, leading to an ED visit where hospital documentation referenced a possible fall, but the facility did not obtain or scan the full hospital record into the EMR. Upon the resident’s return, there was no documented comprehensive assessment, no fall investigation, and no documented notification of the provider or management about a possible fall. Further changes in function and symptoms were documented but not acted upon as a change in condition. The resident’s functional status declined from one-person assist to needing two-person assist with a sit-to-stand device due to new onset sciatic pain, and a provider note documented right-sided sciatica that was not improving, leading to an order for gabapentin. Despite this, there was no documentation of a comprehensive assessment related to the new pain, the need for mechanical lift assistance, or the large bruise later identified. On a subsequent day, a nurse and the family member observed a large bruise and hematoma on the resident’s lower back and right thigh, and the resident reported that she had fallen in the bathroom several days earlier. An incident report was then completed, and management and the physician were notified, but this occurred several days after the alleged fall. During this period, documentation showed a marked increase in urinary and new bowel incontinence, a decline in ADL independence, and a downward trend in hemoglobin levels, yet there was no documented recognition or reporting of these as significant changes in condition. When the resident was ultimately transferred to the hospital, imaging revealed multiple new and worsened fractures, including comminuted bilateral sacral fractures with anterior subluxation of S1 on S2, pelvic fractures, and a large right buttock hematoma. Hospital consultants documented that she had cauda equina on presentation with no rectal tone and overflow incontinence, and that the fractures appeared new and worse compared to prior imaging, while facility records lacked timely assessments, investigations, and notifications consistent with the facility’s fall management policy and nursing standards cited in the report. The facility’s own fall management policy required licensed nurses to complete incident/accident reports, document in the medical record and 24-hour report, notify the attending physician and responsible party of falls, and communicate falls to the interdisciplinary team. Fundamentals of Nursing references cited in the report emphasized the need for comprehensive assessments, timely reporting of significant changes in condition, and accurate, complete documentation. In this case, the record showed no timely incident report or investigation on the date of the alleged fall, no documented assessments of the large bruise when first identified, no documented follow-up on the ED note referencing a possible fall, and no documented recognition or reporting of the resident’s new or worsening pain, functional decline, continence changes, and hemoglobin drop as changes in condition. The NHA confirmed that staff did not report the injury following facility policy, that management was not notified of the alleged fall and injury until several days later, and that staff should have identified and reported the injury during daily care based on its size and extent.
Failure to Follow Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication and treatment administration for multiple residents. For one resident with an order for lorazepam twice daily, the controlled drug record showed only one dose dispensed on several days, while the medication administration record documented two doses as given, indicating a discrepancy in controlled medication handling and documentation. Another resident with an order for metoprolol, which included specific blood pressure and pulse parameters, received the medication even when the required assessments were not performed or when the parameters were not met, such as administering the drug when the systolic blood pressure was below 120 or the pulse was below 60, contrary to the physician's order. A third resident with congestive heart failure had a physician's order for daily weights and notification if weight increased by more than 2.5 pounds in 24 hours or 5 pounds in a week. Documentation showed missing daily weights, repeated use of a previous day's weight, and a failure to notify the provider when the resident's weight increased by more than 2.5 pounds in 24 hours. For another resident with a fentanyl patch order, the patch was not changed as scheduled, and the resident was observed with a medication cup containing multiple pills and two capsules left on the overbed table, with no assessment completed to determine if the resident could safely self-administer medications. Additionally, on the Oak and Maple Units, several resident treatments were not documented as completed during specific shifts. The facility's documentation practices did not align with professional standards, as required pre-assessment data and timely documentation of medication and treatment administration were not consistently performed. These findings were confirmed through observation, record review, and interviews with facility leadership.
Deficient Food Storage, Sanitation, and Equipment Maintenance
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and sanitation practices within the facility's kitchen and kitchenettes. During the initial kitchen tour, a bag of sliced turkey was found in the refrigerator with unclear dating, and several expired yogurts were discovered in the Masterside Kitchenette refrigeration unit. In the J Wing Kitchenette, nutritional juice drinks and shakes lacked discard dates, and additional expired yogurts were present. The Certified Dietary Manager (CDM) was unable to confirm when certain items were thawed or when the ice machine was last deep cleaned by a vendor. Further inspection revealed unsanitary conditions and improper utensil storage. The inside mechanism of the ice machine had visible black accumulation, and clean utensil drawers contained scoops with dried food debris. The microwave had dried food debris on its interior top, and a disposable Styrofoam cup was found stored in a container of powdered milk. Five spatulas hanging over the preparation table were chipped and torn, yet still in use according to the CDM. Additional deficiencies included improper ice storage and maintenance. Ice chest coolers near the Masterside and J Wing Kitchenettes had visible water accumulation with no means for self-drainage, allowing water to mix with the ice. These findings demonstrate a lack of adherence to professional standards and FDA Food Code requirements for food safety, sanitation, and equipment maintenance, potentially affecting all residents consuming food from the kitchen.
Failure to Ensure Call Light Accessibility and Proper DME Accommodation
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents with significant physical and cognitive impairments. Observations revealed that the call light devices for these residents were consistently placed out of sight and out of reach, such as on the floor near the foot of the bed, on a chair at the foot of the bed, or clipped to an over-bed light. Each of these residents had care plans specifying that call lights should be kept within reach to promote safety and allow them to request assistance as needed. The facility's own policy also required that call lights be accessible to residents in bed or confined to a chair, but this was not followed during multiple observations. Additionally, the facility failed to accommodate the durable medical equipment (DME) needs of a resident with complex physical disabilities, including hemiplegia, contractures, and chronic pain. Despite repeated requests and grievances from the resident, his guardian, and the Ombudsman, the facility did not ensure a proper DME assessment or timely submission of paperwork for an appropriate, comfortable, and safe wheelchair. The resident experienced ongoing discomfort and pain due to an ill-fitting wheelchair lacking necessary features such as a headrest and adequate pressure relief. Multiple communications documented the family's and Ombudsman's efforts to guide the facility through the insurance process, but the facility failed to follow through, resulting in prolonged unmet needs. Interviews with staff, including the Occupational Therapist, Social Worker, and Director of Nursing, confirmed awareness of the resident's discomfort and the family's dissatisfaction. Staff acknowledged the lack of a headrest and the resident's pain, and documentation showed that grievances were filed and marked as unresolved by the guardian. Despite these ongoing concerns, there was no evidence that the facility completed the necessary assessments or submitted required documentation to obtain a properly fitted wheelchair, nor was there documented follow-up from the Nursing Home Administrator on the grievances.
Failure to Respond to Resident Council Grievances
Penalty
Summary
The facility failed to respond to grievances raised by the Resident Council, resulting in an ineffective forum for residents to present concerns and recommendations. The Resident Council President and other members consistently reported two main issues: delayed call light response and untimely meal service. Residents described situations where staff would turn off call lights and leave without meeting their needs, often not returning as promised. Additionally, residents reported long waits for meals, with some waiting over an hour in the dining room before being served. These concerns were repeatedly brought up at Resident Council meetings, but residents stated that the facility did not provide follow-up or feedback on actions taken to address the issues. Documentation reviewed from Resident Council meetings over a six-month period did not reflect any mention of the ongoing concerns about call light response or meal service delays, despite residents' claims that these were recurring topics. Only one individual concern about room cleanliness was documented and followed up. The Activities Director, who facilitated the meetings, stated that concerns were documented and addressed, but the records did not support this. The Nursing Home Administrator was unaware of the Resident Council's concerns, and residents reported that their issues were not revisited or resolved in subsequent meetings. Observations of the dining service confirmed significant delays in meal delivery, supporting the residents' complaints.
Failure to Document and Administer Controlled Medications per Provider Orders
Penalty
Summary
The facility failed to accurately document the administration of controlled medications and did not ensure that controlled medications were administered according to provider orders for four residents. For one resident, temazepam was not documented as dispensed on the Controlled Substances Proof of Use form, despite being recorded as administered on the Medication Administration Record. Additionally, lorazepam was dispensed and documented prior to the start date of the order and after the order had expired, with no corresponding documentation of administration or a physician's one-time order in the medical record. Another resident had lorazepam dispensed on multiple occasions without an active order, and there was no documentation of administration or a physician's order for those instances. For two other residents, hydrocodone-acetaminophen and lorazepam were dispensed as indicated on the Controlled Substances Proof of Use forms, but there was no documentation on the Medication Administration Record that these medications were administered. The lack of documentation for as-needed medication administration impedes the ability to assess ongoing need and symptom control. The DON and NHA confirmed these medication administration and documentation errors during interviews, and facility policy requires medications to be administered per physician orders and documented accordingly.
Failure to Use Wheelchair Footrests During Resident Transport
Penalty
Summary
Facility staff failed to safely transport six residents in wheelchairs by not ensuring the use of footrests during movement throughout the facility. Multiple observations documented staff, including CNAs and an activities aide, pushing residents in wheelchairs without footrests attached or without the residents' feet placed on the footrests. In several instances, residents' feet were observed dragging on the floor while being transported, and in one case, a resident was wearing grip socks while her foot dragged. These actions occurred in various locations, such as from dining rooms to nurses' stations, down hallways, and to resident rooms. The residents involved had significant medical histories, including Alzheimer's disease, unsteadiness on their feet, muscle weakness, history of falls, dementia, epilepsy, and left-sided weakness following a stroke. All residents reviewed for this deficiency were noted to be severely cognitively impaired, as indicated by low BIMS scores. Staff interviews confirmed that facility policy requires residents' feet to be securely on footrests when being pushed in wheelchairs, but this was not followed during the observed incidents.
Failure to Ensure Dignified Care, Timely Assistance, and Communication for Residents
Penalty
Summary
The facility failed to provide dignified care and timely assistance to two residents who required help with toileting and mobility. One resident, who was non-weight bearing on both lower extremities and required assistance for toileting, reported that staff did not respond promptly to call lights, sometimes turning them off without providing the needed help. This resident experienced episodes of incontinence and humiliation after being told by staff to defecate in bed due to the unavailability of a bed pan, despite being continent and able to make his own medical decisions. The resident began wearing briefs out of concern that staff would not respond in time to his needs. Another resident, also cognitively intact and able to make her own medical decisions, reported similar issues with delayed call light response and staff turning off the call light without returning to assist. As a result, this resident experienced incontinence and emotional distress. Both residents' experiences were corroborated by their own accounts and observations during the survey, and the facility's policy required call lights to be answered promptly and not turned off until the resident's needs were met. Additionally, the facility failed to ensure effective communication and self-determination for a Spanish-speaking resident who was dependent on staff for all transfers and toileting hygiene. The medical record indicated that this resident was her own decision maker, but there was no communication care plan in place to guide staff in engaging her in her care. Documentation showed that staff and medical providers did not consistently use translation services, resulting in the resident being unable to communicate her needs or participate in care decisions, including pain management and reporting incidents such as falls.
Failure to Maintain Resident Dignity Due to Delayed Incontinence Care
Penalty
Summary
A male resident with severe cognitive impairment, who was fully dependent on staff for all daily needs, was observed sitting in a broda chair at the dining room table with visibly wet pants from urine. This condition persisted for over an hour, as multiple observations noted the resident remained in the same state, both in the dining room and later when moved to the nurses station. The resident's sweat pants continued to be visibly wet in the crotch area until staff eventually took him to his room to change his clothing and provide peri-care. These observations indicate that the facility failed to maintain the resident's dignity by not promptly addressing his incontinence and ensuring he was clean and dry.
Failure to Accurately Document Dialysis on MDS Assessment
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for one resident who was receiving hemodialysis. According to the Resident Assessment Instrument manual, Section O is intended to document any special treatments, procedures, or programs, including dialysis, that a resident receives during the specified look-back period. Review of the facility's records and interviews confirmed that the resident regularly left the facility three times a week to receive dialysis treatment. Despite this, multiple MDS assessments for the resident, including admission and subsequent assessments, did not indicate that the resident was receiving dialysis. The MDS Coordinator/Registered Nurse verified that the dialysis treatment was not marked on the MDS, even though the resident was actively receiving it. This omission resulted in the resident's MDS assessments being inaccurate regarding their special treatments.
Failure to Develop and Implement Communication Care Plan for Non-English Speaking Resident
Penalty
Summary
A Spanish-speaking resident with bilateral leg amputations was admitted to the facility and was her own responsible party. Despite her language needs being documented in the medical record, there was no comprehensive communication care plan in place to guide staff on how to effectively communicate with her. The electronic medical record did not contain a care plan addressing her communication needs, and staff documentation indicated that the resident was unable to describe incidents, such as a fall, due to the language barrier. There was no evidence that translation services or Spanish-speaking staff were consistently utilized to facilitate communication with the resident. Medical provider documentation acknowledged the resident's exclusive use of Spanish and noted challenges in assessing her pain and obtaining her input during evaluations. The provider was not Spanish-speaking, and there was no indication that translation services were used during medical assessments. Interviews with facility leadership confirmed that, prior to a specific date, no communication care plan existed for the resident, and it was unclear if available Spanish-speaking staff had direct contact with her.
Failure to Complete Comprehensive Assessments and Notify Provider of Change in Condition
Penalty
Summary
The facility failed to ensure comprehensive nursing assessments were completed and did not identify or notify the provider of a change in condition for one resident with significant chronic respiratory conditions. The resident, a male with progressive multifocal leukoencephalopathy and a history of multiple hospitalizations for sepsis, aspiration pneumonia, and acute respiratory distress, required frequent monitoring and interventions, including suctioning and temperature management. The resident's care plan specifically instructed staff to observe for and report signs and symptoms of acute respiratory insufficiency and infection, and to document and communicate abnormal findings to the physician. Despite these instructions, after the resident's return from a recent hospitalization, there was no documentation of a provider assessment or a comprehensive respiratory assessment by licensed nurses. The last full set of vital signs was recorded on one date, with only sporadic temperature checks thereafter, even though the resident experienced a fever and was administered Tylenol. The provider was notified of the fever and instructed staff to manage it in-house, with the expectation of continued monitoring, but there was no evidence of ongoing temperature monitoring or further sepsis screening evaluations until the resident was found unresponsive and subsequently pronounced deceased. Interviews confirmed that the facility's nursing home administrator expected nurses to assess temperatures when administering Tylenol for fever and to complete respiratory assessments for residents returning from hospitalization due to respiratory illness. However, these assessments were not completed, and there was no provider assessment following the resident's readmission, despite the resident's complex medical history and recent acute changes in condition.
Failure to Prevent and Appropriately Manage Facility-Acquired Pressure Ulcer
Penalty
Summary
The facility failed to prevent the development of a facility-acquired pressure ulcer and did not follow its own policies and procedures regarding pressure ulcer care for one resident. Upon admission, the resident had no pressure ulcers and was assessed as low risk for developing them. However, a new stage II pressure ulcer developed on the resident's left heel during their stay. Documentation regarding the wound was inconsistent, with conflicting assessments about the stage and origin of the ulcer. The care plan was not updated with new interventions after the onset of the pressure ulcer, despite evidence of deterioration and changes in the wound's condition. Observations revealed that the resident's heels were resting on the footboard while sitting up in bed, which was not addressed in the care plan. The facility's policy required that preventative measures and care plan updates be implemented and documented for residents at risk or with pressure injuries, but these steps were not followed. Additionally, staff interviews indicated confusion about the resident's wound status and history, further highlighting lapses in assessment and care planning.
Failure to Implement Pharmacy Recommendation for Psychoactive Medication
Penalty
Summary
A deficiency occurred when the facility failed to act upon a pharmacy recommendation regarding the administration of a psychoactive medication for one resident. The resident, who was admitted with non-traumatic brain dysfunction and had moderate cognitive impairment as indicated by a BIMS score of 10 out of 15, was prescribed Lorazepam as needed without a stop date. The pharmacy conducted a drug regimen review and recommended that as-needed non-antipsychotic psychotropic drugs be limited to 14 days unless the prescriber documented the specific condition being treated, the rationale for the extended use, and the duration of the order. The physician accepted this recommendation in writing. Despite the physician's acceptance, the order for Lorazepam remained active beyond the recommended 14-day period without a documented stop date, specific condition, or rationale for continued use. Review of the electronic medical record confirmed that the pharmacy's recommendation was not implemented, and the resident continued to receive Lorazepam past the recommended stop date. The deficiency was acknowledged by the Director of Nursing after being informed of the oversight.
Infection Control Failures in Wound Care, Peri-Care, and Blood Glucose Monitoring
Penalty
Summary
The facility failed to implement proper infection control practices during wound care, peri-care, and blood glucose monitoring for three residents. In one instance, an LPN performed surgical wound care on a resident with necrotizing fasciitis and diabetes, changing gloves without performing hand hygiene and allowing the tail end of the wound packing gauze to touch the resident's clean brief and leg. After completing the dressing change, the LPN removed her gown and gloves, fixed her hair without hand hygiene, and left the room to find hand sanitizer. The facility's policy required hand hygiene between glove changes and after glove removal, as well as preventing clean dressing materials from contacting unclean surfaces. In another case, a CNA provided peri-care to a male resident with severe cognitive impairment and total dependence, cleaning the perineal area in an incorrect sequence that could introduce microorganisms into the urethra. After care, the CNA did not sanitize the broda chair that had been in contact with the resident's urine-soaked clothing. Additionally, an LPN was observed performing a blood glucose test on a resident in a communal dining area, without providing privacy, contrary to facility policy and best practices. The DON confirmed that this practice was not acceptable and did not align with facility procedures.
Failure to Conduct Fire Drills at Unexpected Times and Varying Conditions
Penalty
Summary
The facility failed to conduct fire drills at unexpected times and under varying conditions as required by regulations 19.7.1.4 through 19.7.1.7. Record review on April 9, 2025, showed that first shift fire drills in the first quarter were held at similar times in the morning, specifically at 10:00 am and 10:30 am, while third shift drills in the first and second quarters were both conducted around 3:30 am and 3:40 am. This pattern indicates a lack of variation in the timing and conditions of the fire drills. The deficiency was confirmed through an interview with the facility Maintenance Director during the observation period.
Plan Of Correction
K712 Fire Drills Element 1: There have been no negative effects concerning residents related to the fire drills not being conducted at unexpected times, under varying conditions. Element 2: Residents that reside in the facility have the potential to be affected by this deficient practice. Element 3: The Maintenance Department was educated by the Nursing Home Administrator on conducting fire drills on all shifts at unexpected times, under varying conditions. Element 4: Facility fire drills will be audited monthly for 4 months to ensure completion at unexpected times, under varying conditions. Variances will be corrected as indicated. Audit results will be forwarded to the facility's quality assurance committee for review and further recommendations. Additional education and monitoring will be initiated for any identified concerns. Facility Administrator will be responsible for sustained compliance.
Failure to Document Required Generator Battery Testing
Penalty
Summary
The facility failed to document a required battery test during the monthly inspection of its generators. Specifically, the monthly test did not include either the specific gravity fluids or the cold crank amperage for maintenance-free batteries, as required to ensure the operational condition of the generator cells. This omission was identified during a record review conducted on April 9, 2025, and was confirmed through an interview with the facility Maintenance Director at the time of observation. The deficiency pertains to non-compliance with NFPA 110, which mandates that such battery tests be part of the monthly generator inspection. The lack of documentation and testing could potentially affect all occupants and staff in the event of a failed generator battery during a main utility power loss, as the operational readiness of the emergency power source could not be verified.
Plan Of Correction
K918 Electrical Systems Element 1: Facility purchased tester for generator battery. Battery tested and is in operational condition. Element 2: Residents that reside in the facility have the potential to be affected by this deficient practice. Element 3: The Maintenance Department was educated by the Nursing Home Administrator on monthly generator inspections to include a documented battery test. Element 4: Facility generator checks will be audited monthly for 4 months to ensure monthly generator inspections include a documented battery test. Variances will be corrected as indicated. Audit results will be forwarded to the facility's quality assurance committee for review and further recommendations. Additional education and monitoring will be initiated for any identified concerns. Facility Administrator will be responsible for sustained compliance.
Improper Positioning of Kitchen Hood Filter System
Penalty
Summary
During an observation of the facility's main kitchen, it was found that the kitchen hood filter system located above the commercial stove and appliances had a filter that was partially out of position. The filter was observed resting on top of another filter, which resulted in the system not maintaining a tight seal as designed. This improper positioning of the filter compromised the system's ability to prevent grease-laden vapors from entering the plenum space above. The finding was confirmed through an interview with the facility Maintenance Director at the time of observation. No information regarding specific patients, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K0324 Cooking Facilities Element 1 The filter in the main kitchen hood system was serviced and adjusted to maintain a tight system for the prevention of grease-laden vapors to enter above into the plenum space. Element 2 Kitchen hood system was checked to ensure that all filters are placed and fitted appropriately to maintain a tight system. No other concerns were identified. Element 3 The Maintenance Department was educated by the Nursing Home Administrator on checking the hood system for proper filter placement, ensuring a tight system is in place. Element 4 Kitchen hood system will be checked for proper filter placement weekly for 4 weeks, then monthly for 3 months to ensure a tight system for the prevention of grease-laden vapors to enter above into the plenum space. Variances will be corrected as indicated. Audit results will be forwarded to the facility's quality assurance committee for review and further recommendations. Additional education and monitoring will be initiated for any identified concerns. Facility Administrator will be responsible for sustained compliance.
Improper Use of Power Strips in Patient Care Area
Penalty
Summary
A deficiency was identified when, during an observation in the physical therapy area at the staff desk, a power strip was found plugged into a second power strip, with several items drawing power from this setup. This arrangement does not comply with NFPA 99 and NFPA 70 requirements regarding the use of power strips and extension cords in patient care areas. The improper use of power strips was confirmed through an interview with the facility Maintenance director at the time of observation. The report specifically notes that the power strips were not being used in accordance with the required safety standards, as outlined in the referenced NFPA codes, and that this practice could potentially affect 12 occupants and staff.
Plan Of Correction
K920 Power Cords and Extension Cords Element 1: Power strips in the Therapy Room were removed from service. Element 2: Residents that reside in the facility have the potential to be affected by this deficient practice. Element 3: The Maintenance Department was educated by the Nursing Home Administrator on completing checks within the facility to ensure that power strips and extension cords are not in use outside of temporary work being completed. Element 4: Facility rounds will be audited weekly for 4 weeks, then monthly for 3 months to ensure monthly power strips and extension cords are not inappropriately in use. Variances will be corrected as indicated. Audit results will be forwarded to the facility's quality assurance committee for review and further recommendations. Additional education and monitoring will be initiated for any identified concerns. Facility Administrator will be responsible for sustained compliance.
Failure to Update Facility Assessment Reflecting Current Census and Staffing
Penalty
Summary
The facility failed to review and revise its facility-wide assessment to accurately reflect the current resident census and acuity. During an entrance conference, the Nursing Home Administrator (NHA) reported a current census of 93 residents, while the facility assessment was based on an outdated Resident Population Profile with an average daily census of 73 residents. Additionally, the Core Staffing and Personnel Audit attached to the assessment had not been reviewed since August 6, 2024. The assessment also failed to update the roles of the NHA and the Director of Nursing (DON), which had changed since July 10, 2024. The NHA, who had been in the position for 90 days, was unaware of the need to update the Facility Assessment.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by another resident. Resident #1, who was admitted with diagnoses including dementia and a mood disorder, exhibited severe cognitive impairment and inappropriate sexual behaviors. These behaviors were documented in a mental health consult note, which included incidents of public masturbation and attempts to expose himself. Despite being on a care plan that required direct supervision when out of bed and 15-minute checks, Resident #1 was not adequately monitored. On the night of the incident, Resident #1 was found in Resident #2's room, engaging in non-consensual sexual contact. Resident #2, who was also severely cognitively impaired with a BIMS score of 00/15, was found naked and unresponsive to the situation. The staff member who discovered the incident, CNA B, reported that Resident #1 was pulling Resident #2's head towards his body. Despite the care plan interventions, Resident #1 was not under direct supervision at the time, and staff were unaware of his whereabouts. Interviews with staff revealed a lack of clarity regarding who was responsible for supervising Resident #1. Multiple staff members, including CNAs and an LPN, acknowledged that Resident #1 required direct supervision and 15-minute checks but were unable to account for his location or actions leading up to the incident. The facility's abuse prohibition policy, which mandates monitoring to ensure residents are free from abuse, was not effectively implemented, resulting in the failure to prevent the abuse incident.
Failure to Monitor Blood Pressure Before Medication Administration
Penalty
Summary
The facility failed to monitor blood pressures and follow physician-ordered parameters before administering blood pressure medications to a resident, identified as R3, who was reviewed for medication parameter monitoring. R3, a resident with a history of hypertension and Torsades de Pointes, had specific physician orders to withhold medications such as amlodipine, lisinopril, and metoprolol if the systolic blood pressure was below 110 mmHg. Despite these orders, the medications were administered on multiple occasions when R3's blood pressure was below the specified threshold or when no blood pressure reading was obtained prior to administration. The Medication Administration Records (MARs) for R3 from November 1, 2024, to January 21, 2025, revealed numerous instances where blood pressure medications were given without adhering to the required monitoring. On several dates, the medications were administered even when the recorded blood pressure was below the threshold, such as readings of 92/56 mmHg and 106/58 mmHg. Additionally, there were multiple days when blood pressure readings were either not obtained at all or were taken several hours after the medications had been administered, contrary to the physician's orders. During an interview, the Nursing Home Administrator acknowledged the discrepancies in the MARs and the absence of blood pressure monitoring on certain days. The administrator noted that the pharmacy had removed the blood pressure documentation boxes from the MARs starting in December 2024, which may have contributed to the oversight. The failure to monitor and document blood pressure readings as per the physician's orders resulted in a deficiency, highlighting a lapse in the facility's medication administration process.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident with severe intellectual disabilities, major depressive disorder, anxiety disorders, dysphagia, dementia, and late-onset Alzheimer's Disease. The resident, who was cognitively intact with a BIMS score of 14/15, was subjected to verbal and physical abuse by a CNA while receiving care. The abuse was witnessed by a Certified Nursing Aide in Training (CNAT), who reported the incident to Human Resources. The incident occurred when the CNAT requested assistance from the CNA to provide care to the resident. During the care, the resident was yelling, and the CNA responded by yelling back, using derogatory language, and placing her hand over the resident's mouth. The CNAT reported that the CNA used offensive language and covered the resident's mouth, which was corroborated by the CNAT's interview with Human Resources and the Assistant Director of Nursing. The CNA admitted to raising her voice and placing her finger over the resident's mouth but denied using offensive language. The facility's Abuse Prohibition Policy, which was last revised in September 2022, clearly states that residents should be free from all forms of abuse, including verbal and physical abuse. Despite this policy, the CNA's actions violated the resident's rights and the facility's standards of care. The incident was reported to the State Licensing Board as required by law, and the CNA was subsequently separated from employment due to the violation of the facility's work rules.
Failure to Label and Date Foods and Record Food Temperatures
Penalty
Summary
The facility failed to ensure proper labeling and dating of foods and documentation of food temperatures, affecting 70 residents receiving meals from the kitchen. During an initial tour of the kitchen, surveyors observed 12 cups of strawberry shortcake ice cream in Styrofoam cups, a peanut butter and jelly sandwich in a plastic bag, and approximately 20-8 oz cups of juice, all without labels and dates. The Dietary Manager confirmed that these items should have been labeled and dated. Additionally, a review of the time/temperature food preparation log revealed missing temperature recordings for coleslaw on one date and for the entire dinner meal on another date. The Dietary Manager was unsure why these temperatures were not recorded, acknowledging that they should have been completed. The 2017 FDA Food Code and the facility's own policies require that all perishable food items in refrigerators be properly dated, labeled, and stored in appropriate containers. The policies also mandate that food temperatures be taken and recorded for all Time/Temperature Control for Safety (TCS) foods at all meals. The failure to adhere to these standards increased the risk of contaminated foods and foodborne illness among the residents. The facility's Food Purchasing and Storage Policy and Food Temperatures Policy were not followed, leading to this deficiency.
Improper Maintenance of Outdoor Dumpsters
Penalty
Summary
The facility failed to effectively maintain the outdoor dumpsters, affecting 70 residents. On 4/17/2024 at 10:20 AM, it was observed that the lids of two dumpsters, one for trash and one for cardboard boxes, were not closed. Later, at 1:32 PM, the Maintenance Assistant (MA) confirmed that the trash dumpster lid was stuck and could not be closed, while the cardboard boxes dumpster lid was closed. The Maintenance Director (MD) was unaware of the issue until informed by the MA and mentioned that the frame of the trash dumpster was bent, necessitating a call to the dumpster company for repairs. By 3:15 PM, the MD stated that the trash dumpster lid was fixed. During an interview on 4/18/2024, the Nursing Home Administrator (NHA) admitted that there was no policy regarding the outdoor dumpsters.
Failure to Report and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse for three residents, resulting in allegations of sexual abuse that were not reported to the State Agency. Resident #13, a male with Alzheimer's and other conditions, exhibited sexually inappropriate behaviors, including nudity and making sexual comments to female residents and staff. On multiple occasions, he was observed engaging in inappropriate behaviors, such as attempting to touch a female resident's groin and making sexually explicit comments. Despite these incidents, there was no evidence that these allegations were reported to the proper authorities or that an investigation was completed. Resident #62, a female with dementia and other conditions, was involved in an incident where Resident #13 attempted to touch her inappropriately. Housekeeping staff witnessed the incident and reported it to a Licensed Practical Nurse (LPN), but there was no follow-up or investigation documented. Additionally, Resident #59, a male with advanced dementia, was found inappropriately touching himself in front of Resident #62. This incident was reported to the Director of Nursing (DON), but it was not reported to the State Agency, and no investigation was conducted. Interviews with staff revealed that there were significant gaps in reporting and investigating allegations of abuse. Some staff members were unsure if incidents were reported to management, and others did not recall receiving abuse training. The Nursing Home Administrator (NHA) and DON both acknowledged that the incidents should have been reported and investigated but were not. The facility's failure to report and investigate these allegations of abuse resulted in a deficiency in ensuring the safety and well-being of the residents.
Failure to Investigate and Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure the protection of residents and thoroughly investigate allegations of abuse involving three residents. Resident #13, a male with Alzheimer's and other conditions, exhibited sexually inappropriate behaviors, including nudity and making sexual comments. Despite being on 15-minute checks, he was observed attempting to touch a female resident inappropriately. Staff did not report this incident as an allegation of sexual abuse, and no investigation was conducted. Additionally, there were multiple documented instances of Resident #13's inappropriate behavior that were not followed up with proper incident reports or investigations. Resident #62, a female with severe cognitive impairment, was involved in an incident where Resident #13 attempted to touch her inappropriately. Housekeeping staff witnessed the event and reported it to a nurse, but no further action was taken to investigate or report the incident as abuse. Another incident involved Resident #59 and Resident #62, both with severe cognitive impairments, being found with their hands down each other's pants. This incident was reported to the Director of Nursing, but no investigation was conducted, and it was not reported to the state agency. Interviews with staff revealed that there were significant gaps in reporting and investigating these incidents. Some staff members were unsure if incidents were reported to management, and others did not recognize the behaviors as potential abuse. The facility's Administrator and Director of Nursing were unaware of some incidents and did not follow through with required investigations and reports. Additionally, there were issues with staffing levels, making it difficult to monitor residents adequately, and some staff had not received proper abuse training.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement comprehensive care plans for a resident, resulting in the potential for unmet care needs and impaired wound healing. The resident, who was admitted with diagnoses including unspecified dementia, adult failure to thrive, difficulty in walking, generalized muscle weakness, and a pressure ulcer of the right heel, was observed multiple times without the required heel protection boots. Despite an order for the boots to be worn every shift, the resident was frequently seen without them, both in bed and in a wheelchair. Observations revealed that the resident's heels were often in direct contact with the mattress or wheelchair foot cradle, contrary to the care plan and medical orders. Interviews with staff confirmed that the resident's heels were not consistently offloaded as required. The care plan and Kardex did not accurately reflect the need for the boots to be worn while the resident was in the wheelchair, leading to inconsistent application of the prescribed treatment. The medical record indicated ongoing issues with the resident's right heel pressure ulcer, which required the use of heel suspension/protection devices. Despite documentation showing the boots were signed out as in place, observations and staff interviews revealed that the boots were not consistently used. The facility's failure to ensure the resident's care plan was comprehensive and accurately implemented contributed to the deficiency in care.
Inadequate Staffing Leads to Resident Incidents
Penalty
Summary
The facility failed to ensure sufficient levels of nursing staff to meet the needs of residents, resulting in several incidents involving three residents. Resident #13, a male with Alzheimer's and other conditions, exhibited sexually inappropriate behaviors, including nudity and aggressive actions towards staff and other residents. Despite being on 15-minute checks, he was able to inappropriately touch a female resident, Resident #62, who has severe cognitive impairments. This incident was not properly reported or investigated as an allegation of sexual abuse by the staff or management. Resident #59, who also has severe cognitive impairments, was found inappropriately touching himself in the presence of Resident #62 in an activity room. This incident was reported to the Director of Nursing but was not considered an allegation of abuse, and no investigation was conducted. The facility's staffing levels were insufficient to monitor all residents adequately, leading to these incidents occurring without timely intervention. Interviews with staff revealed that the facility often operated with minimal staff, making it difficult to provide adequate supervision and care. Housekeeping staff also reported assisting with resident care due to the lack of sufficient nursing staff. The facility's failure to maintain appropriate staffing levels and adequately address and report incidents of inappropriate behavior and potential abuse compromised the safety and well-being of the residents involved.
Failure to Label and Dispose of Medications Properly
Penalty
Summary
The facility failed to ensure that opened medications were appropriately labeled and that expired medications were disposed of, as observed in two of three medication carts reviewed. During a review of the Oak Hall Medication Cart, an opened Lantus Solostar Insulin Pen for a resident was found without an open date, making it impossible to determine if it had been used beyond the recommended 28 days. The Registered Nurse/Unit Manager confirmed the issue and disposed of the pen. Similarly, the Maple Hall Medication Cart contained an opened Fluticasone Propionate Inhaler and a Latanoprost Ophthalmic Solution bottle, both lacking open dates. The Licensed Practical Nurse confirmed the medications were active but could not verify their open dates, leading to their disposal due to potential expiration concerns. The medical records of the affected residents showed active orders for the medications in question, with regular administration documented. The Director of Nursing stated that the facility's policy required nurses to label medications with the open date upon initial use and to check expiration dates before each administration. However, the review revealed that this policy was not consistently followed, resulting in the presence of potentially expired medications in the carts. The facility's Medication Storage Guidance form also indicated specific discard timelines for these medications, which were not adhered to in these instances.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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