Regency At Troy
Inspection history, citations, penalties and survey trends for this long-term care facility in Troy, Michigan.
- Location
- 2685 West Maple Road, Troy, Michigan 48084
- CMS Provider Number
- 235733
- Inspections on file
- 13
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Regency At Troy during CMS and state inspections, most recent first.
A resident with diabetes, schizophrenia, and documented prior shallow sacral and gluteal wounds was admitted with hospital orders for Triad ointment and pressure offloading, but no wound or prophylactic skin treatments were initiated and weekly skin checks were not consistently performed despite identified pressure injury risk. Over several months, MAR/TAR records showed no skin treatments, and only a few skin checks were documented. A new right gluteal fold wound, later confirmed as facility-acquired, was first documented by the wound nurse with significant size and sanguineous drainage, but treatment orders were delayed by two days. When a wound NP finally evaluated the resident, the wound was unstageable with 100% slough, malodor, and purulent drainage, prompting hospital transfer where it was diagnosed as a stage 4 pressure injury requiring surgical debridement; the resident reported pain and lack of treatment before hospitalization.
Multiple residents who were dependent for toileting and frequently incontinent experienced prolonged waits for incontinence care and assistance with ADLs, with reports of call lights going unanswered for 45–90 minutes or more and residents being found soaked in urine at the start of shifts. An LPN and a CNA described chronic short staffing, especially at night, with as few as two or three aides caring for around 50–57 residents, resulting in residents routinely waiting 1–2 hours for changes. Cognitively intact residents and their families reported repeated episodes of lying in heavily saturated briefs, missed or delayed showers, and staff turning off call lights without returning, while grievance forms and shower logs documented ongoing patterns of inadequate incontinence care and hygiene that did not align with the facility’s own policy for timely care and call light response.
A resident with moderately impaired cognition, multiple medical conditions, and dependence on staff for ADLs was the subject of a grievance in which the resident’s son reported that staff were being rough, including pulling the resident’s hair and legs, and that the resident had a leg cut and feared retaliation. A Social Services Technician documented the grievance and stated they reported the concern to the Administrator, who also served as the abuse coordinator. The Administrator later stated they were unaware of the allegation and agreed it should have been reported. The facility’s abuse policy required immediate internal reporting of mistreatment allegations and timely notification to State or Federal agencies, but the allegation was not reported to the State Agency as required.
A resident with multiple chronic conditions experienced altered mental status with hallucinations and required supplemental O2. An NP ordered 2L O2 via nasal cannula with titration to maintain SpO2 above 93% and a UA/CS, but the record contained no documented SpO2 readings below 90% and no further respiratory assessments. The resident’s family reported finding the O2 tank empty and tubing on the floor, and was allegedly told by an LPN that UAs are not done on weekends. EMS later found the resident confused, lethargic, hallucinating, and with an SpO2 of 86% on room air, requiring 15 L/min via NRB, and noted they could not obtain history from the nurse. The LPN could not recall key clinical details, acknowledged that an SpO2 of 86% is not stable, and could not explain why documentation described the resident as stable and without O2 at departure, while leadership confirmed that UAs can be obtained on weekends and that required transfer documentation was not provided.
Surveyors found that two residents who required feeding assistance did not receive timely help with meals. One cognitively intact resident with Parkinson’s disease, muscle weakness, and contracted hands had a lunch tray left on a counter for several minutes before staff entered to assist, despite documentation that the resident was dependent on others to bring food and liquids to the mouth and required a mechanically soft diet. Another severely cognitively impaired resident with Alzheimer’s disease and dementia, who required supervision for snacks, did not receive a lunch tray while nearby residents were served and was observed taking and eating another resident’s partially eaten ice cream. A nurse reported there were not enough staff to assist all residents needing help with eating at the same time, and the Administrator later acknowledged uncertainty about the timing of services provided.
A resident with a large surgical wound on the left lower extremity, admitted with an open wound, cellulitis, acute kidney failure, and type II DM, reported that ordered twice-daily wound treatments were not performed as scheduled and that a nurse delayed a dressing change, stating they were too busy. When the dressing was eventually changed, observation showed the wound was only partially covered and a yellow dressing material, likely Xeroform, was used instead of the ordered Opticell AG with ABD pads, kerlix, and Ace wrap. The wound nurse confirmed that the yellow product was not in the physician’s orders and that the wound should have been fully covered, while the facility’s policy required treatments to follow physician or other licensed prescriber orders.
A resident with Parkinson’s disease, muscle weakness, and a history of UTIs, who was cognitively intact but dependent on staff for hydration and feeding, experienced delayed evaluation and treatment for UTI symptoms. The resident reported frequent UTIs, long waits for incontinence care, and needing assistance with drinking, while observation showed food and water placed out of reach. Over several days, staff documented dysuria and suprapubic/flank tenderness, multiple unsuccessful attempts to obtain a urine specimen via straight cath, and the need to repeatedly endorse the task between shifts. A urine sample that was finally collected and refrigerated was mistakenly discarded, further delaying successful specimen collection and confirmation of a positive UA, while the resident continued to report burning and suprapubic tenderness.
A resident with multiple chronic conditions, including CHF and CKD, experienced hallucinations and altered mental status and was ordered 2 L O2 via nasal cannula with titration to maintain SpO2 above 93% and shift monitoring for low saturations. Nursing notes documented hallucinations and oxygen use but did not record any SpO2 values below 90% or additional respiratory assessments, while also noting that the resident repeatedly removed the oxygen and was ultimately sent to the hospital at family request, described as stable and not wearing oxygen. An EMS report documented the resident as confused and lethargic with visual hallucinations and an SpO2 of 86% on room air, requiring 15 L/min O2 via NRB, and indicated EMS could not speak with the nurse. In a later interview, an LPN could not recall key clinical details, including oxygen levels and rounding frequency, and could not explain documentation that conflicted with EMS findings, indicating a failure to provide and document ordered oxygen therapy and respiratory assessment.
A resident with dementia, severe cognitive impairment, communication barriers, and a history of falls was admitted with a prior nasal fracture and required assistance with all ADLs. The facility’s fall assessment categorized the resident as low risk and initiated a general fall care plan, including PT/OT evaluation and environmental safety measures. Over time, the resident experienced multiple witnessed and unwitnessed falls, many at night and some from bed or while reaching for items, yet key care-planned interventions such as PT/OT assessment for assist bars and a reacher were never completed. Instead, the facility repeatedly adjusted psychotropic and anti-anxiety medications (e.g., Alprazolam, Ativan, Seroquel) while the resident continued to fall in both the room and common area. After ongoing falls and agitation, the resident was sent to the hospital at the family’s request, where imaging revealed a left ischial avulsion fracture, and the surveyors cited the facility for failing to implement adequate/effective fall interventions and ensure consistent follow-up of those interventions.
A resident with dementia, Alzheimer’s disease, and severe cognitive impairment exhibited frequent yelling and agitation. The facility repeatedly added and adjusted psychotropic medications (including Xanax, Ativan, Seroquel, Zoloft, and Remeron) without consistently documenting the specific behaviors observed, attempting or recording non-pharmacological interventions first, or clearly indicating appropriate diagnoses such as psychosis or anxiety. Behavior and mood care plans were delayed and not fully individualized, and there was no evidence of systematic behavioral monitoring, tracking of targeted behaviors, or monitoring for adverse effects of antipsychotic and antianxiety drugs. Despite a documented incapacity and an activated DPOA, the facility did not obtain informed consent for multiple psychotropic medications or behavioral health services, and there was no documented involvement of psychiatric or specialized mental health services, leading to a deficiency for failure to provide necessary behavioral health care and services.
Two residents experienced deficiencies in medication management when staff failed to reconcile medication orders accurately and did not administer or document medications as ordered. One resident did not receive scheduled and PRN pain medications on time, while another received Oxycodone every four hours instead of as needed, even when reporting no pain. LPNs and the DON confirmed issues with timely administration, documentation, and order verification.
Surveyors found that insulin pens were not properly labeled or dated after opening, with one pen stored in the wrong resident's bag and several pens lacking open dates. Nursing staff confirmed that these labeling and dating practices were not followed after the facility switched to insulin pens.
A facility failed to properly assess, monitor, and document catheter care for three residents with indwelling urinary catheters. One resident experienced severe pain, lack of urine output, and was not promptly sent to the hospital, resulting in septic shock and death. For two other residents, there was no documentation of urine output or catheter care despite orders and care plan requirements. Staff interviews revealed inconsistent practices and lack of clarity regarding catheter care protocols, and the facility's own policy was not followed.
Two residents experienced deficiencies in their electronic medical records, including missing documentation of ADL care, incomplete care plans, and lack of records regarding a hospital transfer and medication administration. The DON confirmed issues with documentation and acknowledged that records from hospital visits were often missing, contrary to facility policy.
The facility failed to adhere to food safety standards, as frozen turkey breasts were improperly thawed in a sink without running water, contrary to FDA guidelines. Additionally, the kitchen was found to have unsanitary conditions, with soiled counters and improper storage of clean utensils. The facility also lacked proper sanitation practices, as wiping cloths were not stored in a sanitizer solution.
The facility failed to maintain resident dignity and respect, as evidenced by incidents involving three residents. One resident was left unattended and disrespected by a staff member during a shift change. Another resident expressed concerns about staff not wearing name tags, leading to confusion. A third resident and their family member reported rough and disrespectful care by a staff member. These incidents highlight the need for improved staff-resident interactions.
The facility failed to document, investigate, and resolve grievances raised by residents during council meetings. Residents reported not being informed about plans to address issues like long call light wait times. A review of meeting minutes showed recurring concerns, but the facility lacked documentation of resolutions, as confirmed by the Assistant Administrator and RDO.
A facility failed to promptly respond to call light requests, leaving residents in soiled briefs and without necessary assistance. One resident, with a history of stroke and UTIs, was left in a soiled brief for hours, raising infection concerns. Other residents reported similar delays, particularly in the evenings, despite requiring staff assistance for daily activities.
The facility failed to implement timely and consistent interventions for two residents, leading to potential risks for falls and accidents. One resident, with severe cognitive impairment, was without a wanderguard and proper wheelchair safety measures, resulting in multiple falls. Another resident sustained a skin tear during care due to a CNA not following instructions. Staff interviews revealed a lack of awareness and monitoring of required interventions.
The facility failed to follow infection control practices, with staff not using PPE for residents on contact precautions and not performing hand hygiene during medication administration. A CNA entered a resident's room without PPE, and an LPN did not perform hand hygiene between administering medications. Additionally, staff did not wear gowns while providing care to a resident under Enhanced Barrier Protection.
A resident with asthma and other conditions was not provided with an appropriate bed, leading to discomfort and potential skin issues. Despite the resident's complaints about the bed being too short, no action was taken to provide a longer bed, and there was no documentation of the resident's skin condition or follow-up actions. The acting DON acknowledged the lack of documentation and the need for follow-up.
A resident with chronic conditions did not receive their prescribed Norco pain medication on two evenings due to the facility running out of the medication and failing to reorder it in a timely manner. The facility's established process for using backup medication supply was not followed, resulting in a lapse in medication administration.
A facility failed to implement physician orders for a resident with edema, leading to untreated swelling and drainage. Despite orders for compression stockings and gauze wraps, the resident reported not receiving these treatments, and observations confirmed their absence. The treatment administration record inaccurately documented the application of stockings, and a new order was not processed due to incomplete details. The ADON acknowledged the oversight and indicated the issue would be addressed.
The facility failed to provide adequate pressure ulcer care for two residents, leading to the development of in-house acquired ulcers and improper offloading. One resident, with severe cognitive impairment and multiple diagnoses, had inconsistencies in wound documentation and missing treatments. Another resident, with a heel ulcer, experienced pain due to improper positioning. The facility's documentation discrepancies and lack of specific policies contributed to these deficiencies.
A resident admitted for short-term skilled nursing and rehabilitation experienced significant weight loss due to the facility's failure to implement consistent weight monitoring. Despite family concerns about the resident's lack of appetite, the facility did not obtain an accurate admission weight or conduct weekly weight checks as required by their policy. Interviews with staff revealed a lack of adherence to the weight management policy, resulting in the potential for unidentified weight loss and malnutrition.
A resident with severe cognitive impairment and aggressive behaviors did not receive comprehensive behavioral care management. The resident faced communication barriers due to language differences, and staff failed to utilize effective communication tools. Social services interventions were lacking, and the resident's psychosocial needs, including grief support, were not adequately addressed.
The facility failed to securely store medications, leaving them in residents' rooms, contrary to policy. Observations revealed unsecured medications, including Dakin Solution and Wound Cleanser, in rooms of residents with impaired cognition. Additionally, a resident had medications on their bedside table without self-administration orders. The facility's policy mandates that medications be locked unless approved for self-administration.
A facility failed to complete a timely laboratory diagnostic as per a physician's order for a resident with heart failure and chronic kidney disease. A STAT CBC with differential and CMP were ordered, but only the CMP results were available. The nurse manager confirmed the absence of the CBC results, suggesting an oversight with the lab requisition, and no requisitions for the CBC were found.
A resident with multiple health conditions did not receive an alternative menu despite requests, leading their family to bring outside food. Staff were unaware of the alternative menu's existence, and the facility failed to adhere to its policy of providing alternate meal options.
A resident with dysphagia and a PEG tube was served unrecognizable pureed meals without clear identification on meal tickets, leading to dissatisfaction and complaints from the resident and their family. The facility's policy did not require listing foods on meal tickets, contributing to the issue.
A resident admitted for rehabilitation after a stroke, with a history of diabetes and uterine cancer, did not receive scheduled showers as per facility policy. Despite the policy requiring showers twice a week, documentation showed the resident only received two showers since admission, leading to complaints and frustration. The DON acknowledged the discrepancy when presented with the evidence.
A facility failed to perform physician-ordered dressing changes for a resident with multiple pressure ulcers, including stage IV and unstageable ulcers. The resident's treatment administration record showed missed treatments on several shifts, and an observation revealed outdated dressings with drainage. The Director of Nursing confirmed that treatments should follow physician orders, but the facility's policy on skin management was not adhered to, potentially compromising the resident's care.
A facility failed to implement appropriate transmission-based precautions for a resident with multiple medical conditions and devices, including a PICC line and pressure ulcers. The resident's room lacked signage and PPE supplies, and staff were observed providing care without wearing gowns, despite orders for enhanced barrier precautions. The DON confirmed the need for such precautions, aligning with the facility's policy.
A resident reported grievances about improper care, including a CNA refusing assistance with personal hygiene and a nurse making an inappropriate comment. Despite the facility's awareness, there was no documentation or resolution of these grievances, violating the resident's rights.
The facility failed to follow proper sanitation and food storage procedures in the kitchen, affecting all 78 residents. Observations included an opened tub of ricotta cheese without a date, an insulin pen stored with food, and an employee's cellphone charging in the dry food storage area. Open and undated food items were found, and the cleaning schedule had not been implemented for December. The facility's policy lacked guidance for these issues.
A resident experienced delayed care due to the facility's failure to timely identify and address a change in respiratory condition. Despite abnormal oxygen saturation levels, staff did not intervene or notify a physician until hours later. Monitoring devices were not operational, leading to manual vital checks. The resident was transferred to the hospital and did not return.
A resident with a stage 3 pressure ulcer experienced delayed and omitted wound treatments and antibiotic doses at an LTC facility. The facility failed to apply wound treatments as ordered, did not document reasons for changing antibiotics, and missed several doses of Clindamycin. The resident's wound worsened, and the facility did not identify or report the deterioration, leading to a hospital transfer for higher care.
A resident with a femur fracture and moderately impaired cognition was transferred to the hospital without proper documentation of the transfer date or reason. The facility's policy required documentation from a physician or non-physician practitioner, which was missing. Interviews revealed that the Director of Nursing and a Wound Practitioner could not provide the necessary documentation or explanation for the transfer.
Failure to Perform Weekly Skin Assessments and Timely Wound Treatment Resulting in Stage 4 Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to timely assess and treat a resident at risk for pressure ulcers, resulting in the development of a facility-acquired stage 4 pressure ulcer that required hospitalization, surgery, and caused pain. The resident, who had diagnoses including a right buttock pressure ulcer (stage 4), type II diabetes, and schizophrenia, was cognitively intact with a BIMS score of 13/15 and had Braden scores indicating mild risk for pressure ulcers. Hospital discharge records from an earlier admission documented a sacral shallow partial thickness wound and a shallow partial thickness left gluteal wound, with specific instructions to cleanse the buttocks and sacrum and apply Triad ointment twice daily and as needed, along with continued use of a pressure mattress. However, on admission back to the facility, the wound nurse reported observing no open areas and no treatment orders were initiated based on the hospital’s discharge instructions. Subsequent documentation showed inconsistencies and gaps in skin assessments and treatment. A nursing comprehensive skin evaluation on 11/18/25 documented "no risk" and noted a left trochanter open area and left buttocks areas not open, while a skin/wound progress note on 11/19/25 stated there were no active wounds. The MDS completed on 11/23/25 indicated the resident was at risk for developing pressure ulcers but did not identify any existing pressure ulcers over bony prominences. Review of the MAR/TAR and treatment orders for November 2025, December 2025, and January 2026 showed no evidence that any wound or prophylactic skin treatments were provided during that period, despite the resident’s identified risk and prior hospital instructions. The facility’s wound nurse later confirmed that, although facility policy required weekly skin checks by licensed nurses, the resident had only four documented skin checks since initial admission. On 2/12/26, the wound nurse documented a new, in-house acquired wound in the right gluteal fold, with measurements of 5.11 cm by 4.25 cm and sanguineous drainage, and identified it as acquired in the facility. The wound nurse stated that, based on the wound’s appearance, it was not newly acquired on that date and that the lack of weekly skin checks prevented determination of the actual onset. Treatment orders to cleanse the right gluteal fold wound, apply Triad paste, and cover with dressing were not entered until 2/14/26, two days after the wound was first documented. On 2/17/26, a wound NP evaluated the resident for the first time, describing the right gluteal fold wound as an unstageable pressure injury measuring 4 x 4 x 5.9 cm with 100% slough, a small draining hole, malodor, and purulent drainage, and arranged for transfer to the hospital. Hospital records from 2/17/26 to 2/24/26 documented a right ischial stage 4 pressure injury status post debridement, with an 8 x 5.5 x 4.5 cm wound, soft tissue infection with abscess, and cultures growing S. aureus and ESBL E. coli. The resident later reported that the wound on their bottom hurt, that they did not receive treatment before going to the hospital, and that some staff were rude and did not always provide help. The DON, who was not employed at the time of the events, confirmed that under facility protocol the resident should have received timely and at least weekly skin assessments. The facility’s skin management policy required identification of residents at risk for skin compromise, weekly skin checks by licensed nurses with documentation of findings, prompt reporting of new skin impairments by CNAs to licensed nurses, and monthly IDT "Resident at Risk" meetings to evaluate skin changes and interventions. Interviews revealed that the wound nurse relied on nursing staff and CNAs to report skin issues, but one nurse identified by first name denied reporting skin concerns to the wound nurse, and another nurse did not respond to the surveyor’s call. The wound nurse acknowledged that no treatments were initiated from the hospital’s discharge orders because they believed there were no open areas on admission, and that the right buttock wound was facility-acquired. The combination of failure to continue ordered prophylactic treatments, failure to perform and document weekly skin assessments, delay in initiating treatment after the wound was identified, and lack of timely escalation to wound specialist care led to the resident’s in-house acquired pressure injury progressing to a stage 4 wound requiring surgical debridement and causing pain.
Failure to Provide Timely Incontinence and ADL Care Leading to Prolonged Periods in Soiled Briefs
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and adequate assistance with activities of daily living (ADLs), specifically incontinence care and hygiene, for multiple residents. Complaints reviewed by the State Agency alleged residents waited extended periods for call lights to be answered, resulting in residents lying in urine‑soaked briefs and experiencing poor hygiene. Staff interviews confirmed that residents were sometimes found soaked in urine at the start of shifts, with one LPN stating they could tell residents had been wet for at least 1–2 hours based on dark urine rings in briefs. The LPN also reported that the unit could hold up to 57 residents and that when staffing was reduced to three aides instead of five, residents’ care suffered and call light response and incontinence care were delayed. One resident, who was cognitively intact and dependent for toileting and transfers, reported routinely waiting at least an hour during the day and sometimes more than an hour at night for assistance with brief changes, causing them discomfort and frustration. This resident’s CNA, who worked multiple shifts, corroborated concerns about short staffing, describing assignments of approximately 16–17 residents per aide and many residents being “heavy wetters” requiring two‑person assistance. The CNA stated that at night “everybody was waiting one to two hours” for call lights to be answered and that this resident was sometimes found soaked at the start of the shift. The resident’s family member further reported that on weekends, nights, and holidays, staff frequently called off, leaving as few as two aides on the floor, and that the resident waited 1–2 hours for incontinence care; the family member also stated they had to come in to provide showers when staff did not have time. Another resident, with Parkinson’s disease and moderate cognitive impairment, was dependent for toileting and frequently incontinent. Their family member reported the resident frequently lay 45 minutes to 1 hour in a wet brief, especially at night, and that this problem recurred despite multiple grievances. A grievance documented that the resident was found soaked and crying in the morning after allegedly being left wet all night. A third resident, with severe cognitive impairment, atrial fibrillation, and a UTI, was dependent for toileting and frequently incontinent. Their family member submitted multiple grievances with photographs of heavily urine‑soaked briefs, alleging the resident’s brief was not changed at night on several occasions, that check‑and‑change schedules (every 2–4 hours) were not followed, and that the resident was typically changed only three times per day during a three‑week stay unless the family pushed for an additional change. This third resident’s grievances also described missed showers and lack of timely incontinence care despite prior assurances. The shower log for this resident’s 22‑day stay showed only four shower entries, with only two clearly initialed by staff and one scheduled shower date left blank, leaving no clear verification that showers occurred as scheduled. A fourth resident, cognitively intact and dependent for toileting hygiene and transfers, filed multiple grievances over several months describing call lights left on for 30 minutes to 1.5 hours without assistance, staff turning off call lights and not returning, and going up to a 12‑hour period without personal changing despite using the call light three times. These grievances documented ongoing concerns about extended call light wait times and lack of timely incontinence care. The facility’s own Routine Resident Care policy stated that incontinence care and call light responses were to be provided timely according to each resident’s needs, but the observations, interviews, and grievance records showed this was not consistently done for the residents involved.
Failure to Report Allegation of Rough Care and Mistreatment to State Agency
Penalty
Summary
The facility failed to report an allegation of mistreatment to the State Agency and did not follow its abuse prohibition policy for one resident. A grievance completed by a Social Services Technician documented that the resident’s son reported his mother felt staff were being rough with her, including pulling her hair and legs, and that she had a current cut on her leg. The grievance also documented that the resident was fearful of retaliation from staff. The resident had been admitted with acute respiratory failure, macular degeneration, and conductive hearing loss, had a BIMS score of 8 indicating moderately impaired cognition, and required staff assistance for all ADLs. During interviews, the Administrator, who also served as the facility’s abuse coordinator, stated they were unaware of the rough care and mistreatment allegation and acknowledged that it should have been reported. The Social Services Technician reported that they had informed the Administrator of the concern. The facility’s Abuse Prohibition Policy required staff to report any allegations or suspicions of mistreatment and injuries of unknown source to the Administrator and DON immediately, and required the Administrator or designee to notify State or Federal agencies of allegations per state guidelines (within 2 hours for abuse or serious injury, and all others within 24 hours). This required reporting to the State Agency did not occur for this allegation.
Failure to Provide and Document Appropriate Assessment and Oxygen Management During Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing services met professional standards for a resident with multiple comorbidities who experienced a change in condition with hallucinations and hypoxia. The resident had diagnoses including chronic diastolic CHF, chronic kidney disease, type 2 diabetes with neuropathy, and a history of UTI, and was noted to have a POA daughter as responsible party. On the day in question, nursing documentation showed the resident was hallucinating, with vital signs including BP 124/57, HR 66, and SpO2 90%, and the NP ordered oxygen at 2L via nasal cannula with titration to keep SpO2 above 93%, as well as a UA/CS. A change in condition note documented altered mental status with visual hallucinations and the need for UA and oxygen therapy. Despite these orders, there was no documentation of oxygen saturation levels below 90% in the medical record and no additional respiratory assessments by nursing staff were identified. Later that afternoon, a nursing note stated the resident’s daughter called 911 due to concern about hallucinations and that the resident repeatedly removed the oxygen despite redirection, with staff reapplying the oxygen and providing education. The nurse documented that, per family request, the resident was sent to the hospital in “stable condition,” sitting upright, drinking a beverage, and not wearing oxygen at the time of EMS departure. However, the EMS report documented that upon arrival the resident was confused, lethargic, having visual hallucinations, and had an SpO2 of 86% on room air, requiring 15 L/min O2 via non-rebreather to maintain stable saturations. The daughter reported to EMS that staff had told her a UA could not be done on the weekend, and EMS documented they were unable to obtain history from the nurse because she was not present. In interview, the LPN who documented the nursing notes could not recall the resident’s oxygen saturation level that prompted oxygen therapy, could not recall how often rounding was done to ensure oxygen was in place, and did not remember why EMS was not provided with needed medical information. The LPN was unsure whether she had told the family that UAs are not done on Sundays, acknowledged that UAs are in fact obtained on Sundays, and agreed that an SpO2 of 86% on room air is not stable but could not explain why she documented the resident as stable and without oxygen at departure despite the EMS finding of 86% SpO2 on room air. The DON and Administrator confirmed that UAs can be obtained on weekends and that the nurse should have provided EMS with the medication list, face sheet, and advance directives.
Failure to Provide Timely Feeding Assistance to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with eating for two residents who required feeding assistance. During a lunch observation on the second-floor north hall, no meal trays had been delivered by 12:30 PM, and one resident who required assistance with eating was observed watching another resident eat food that did not appear to be provided by the facility. Trays began to be passed at approximately 12:50 PM, and by around 1:02 PM the nearby resident received a tray, but the dependent resident still had not received lunch. A tray for another dependent resident was delivered to their room at approximately 1:03 PM and left on the entryway counter, with staff not entering to assist until about 1:14 PM. By approximately 1:23 PM, the first dependent resident still had not received a lunch tray and was observed taking and eating a half-eaten cup of chocolate ice cream from the other resident’s tray. When questioned, the nurse on duty stated that the resident needed assistance with eating and that there were not enough staff to help all residents needing feeding assistance at the same time, estimating at least four or five such residents on that hall. Further record review and interviews showed that one of the residents had Parkinson’s disease, depression, muscle weakness, and contracted hands, with an MDS indicating cognitively intact status and dependence on others to bring utensils and liquids to the mouth once the meal was placed in front of them. This resident reported needing assistance with most activities, including eating, and stated they always needed help with meals because they could not use their hands, sometimes did not receive the ordered mechanically soft diet, and at times waited hours to be changed. The other resident had Alzheimer’s disease, dementia with psychotic disturbance, and metabolic encephalopathy, with an MDS BIMS score indicating severe cognitive impairment and an order allowing one mechanical soft snack daily for pleasure with supervision. During an interview, the Administrator stated the facility was well staffed but acknowledged there were times when they were not clear about the timing of services provided.
Failure to Provide Timely and Ordered Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care timely and in accordance with physician orders and the resident’s expectations. A cognitively intact resident with a significant surgical wound on the left lower extremity, admitted with an open wound, cellulitis, acute kidney failure, and type II diabetes, reported that their wound dressing was not changed as ordered. The resident stated that they had an order for wound care twice daily, in the morning and at bedtime, but on one evening the dressing was not changed at bedtime. When the resident asked the assigned nurse about changing the dressing, the nurse reportedly stated they were too busy, citing responsibility for 29 residents, and did not perform the treatment at that time. The resident reported that the wound dressing was not changed until several hours later, in the early morning. When the nurse eventually provided wound care, the treatment did not match the physician’s orders. The resident reported that the nurse used supplies that were unfamiliar to them and, when questioned, told the resident not to worry about what was being applied. Observation of the wound showed that the dressing did not fully cover the wound, leaving approximately one third exposed, and that a yellow padding was attached to the wound, which the resident and family member had not seen used before. Review of the clinical record showed specific orders to clean the left lower extremity wound with wound cleanser, pat dry, apply Opticell AG, ABD pads, wrap with kerlix, and secure with an Ace bandage every day shift and at bedtime, and as needed. The wound nurse indicated that the yellow pads were likely Xeroform, which was not part of the resident’s orders, and confirmed that the wound should have been fully covered per the orders. The administrator acknowledged awareness of the resident’s concerns and that treatment should be provided as ordered, and facility policy required that treatment be rendered in accordance with physician or other licensed health professional orders.
Delayed Urine Specimen Collection and Prolonged UTI Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to obtain a timely urine specimen and initiate prompt evaluation for a resident with a history of UTIs who was cognitively intact but physically dependent on staff for hydration and toileting needs. The resident had Parkinson’s disease, depression, muscle weakness, and contracted hands, and required staff to bring liquids and utensils to their mouth. During observation, multiple cups of water and food were placed out of the resident’s reach. The resident reported needing assistance with most activities, including eating and drinking, and stated they sometimes waited hours to be changed and experienced frequent UTIs. The complaint to the State Agency alleged it took over four days to obtain a urine specimen for suspected UTI and that staff attributed the delay to the resident not drinking enough water, despite the resident’s need for staff assistance with fluids and concerns about staff responsiveness to call lights. Record review showed that the resident first complained of mild pain with urination on 1/31, with this complaint documented on 2/1 and logged for MD follow-up. On 2/2, the NP documented dysuria and mild suprapubic tenderness, encouraged hydration, and ordered a UA with culture. Nursing notes on 2/2 and 2/3 documented attempts to obtain a urine sample, including straight catheterization with very limited backflow and a soaked brief, and the need to endorse the task to oncoming shifts. On 2/4, another unsuccessful attempt was documented, followed by an NP note the same day indicating an acute visit for UTI symptoms, suprapubic/flank tenderness, and collection of a cloudy, odorous urine sample via straight catheter. Nursing notes then documented that this urine sample, placed in the refrigerator, was mistakenly discarded and the need to endorse collection again to the next shift. Further attempts at straight catheterization on 2/5 were unsuccessful, and a positive UA was not documented until 2/7, with continued reports of suprapubic tenderness and burning on 2/11. In an interview, the DON acknowledged difficulty obtaining urine via straight catheter and could not explain why the collected specimen was discarded or the reason for the extended delay in obtaining a usable sample.
Failure to Administer and Monitor Ordered Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure oxygen therapy and maintenance were administered and monitored as ordered for one resident who required respiratory care. The resident had multiple diagnoses, including chronic diastolic congestive heart failure, chronic kidney disease, type 2 diabetes mellitus with diabetic neuropathy, and a urinary tract infection. On the day of the incident, nursing documentation showed the resident was hallucinating, with vital signs including an oxygen saturation of 90%, and the resident was placed on 2 L O2 via nasal cannula per a new clinician order to titrate oxygen to keep saturation above 93% and to monitor oxygen saturation every shift for levels at or below 90%. A change in condition note documented altered mental status and hallucinations, and that the primary care provider ordered a urinalysis and oxygen therapy. Later that afternoon, a nursing note documented that the resident’s daughter called 911 due to concern about the resident’s hallucinations. The note stated the resident repeatedly removed the oxygen despite redirection, that oxygen was replaced but the resident continued to remove it, and that education and reassurance were provided without sustained compliance. The nurse documented that, per family request, the resident was sent to the hospital via EMS in stable condition, and that at the time of EMS departure the resident was sitting upright, drinking a beverage, and not wearing oxygen. However, there were no documented oxygen saturation readings under 90% in the medical record and no additional respiratory assessments were identified, despite the order to titrate oxygen and maintain saturation above 93%. The EMS report for the same day documented that upon arrival the resident was in bed, confused, lethargic, and experiencing visual hallucinations, with an SpO2 of 86% on room air. EMS initiated 15 L/min O2 via non-rebreather mask, which stabilized the oxygen saturation. The EMS report also noted that staff stated EMS was unable to speak to the resident’s nurse because she was not present, and that history was primarily obtained from the daughter, who reported being notified earlier that the resident had low oxygen saturation and that a urinalysis could not be done on the weekend. In a subsequent interview, the LPN who documented the nursing notes could not recall the resident’s oxygen saturation level that prompted oxygen therapy, did not remember how often rounding was done to ensure oxygen was in place, and acknowledged that an SpO2 of 86% on room air would not be considered stable, but could not explain why the resident was documented as stable and without oxygen at the time of EMS departure. Facility policies required respiratory assessments to include pulse oximetry readings and documentation of prescribed interventions and responses, and required oxygen tubing to be kept off the floor.
Failure to Implement and Follow Through on Fall Interventions for a Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate and effective fall interventions and to consistently follow up on fall-related interventions for a resident with dementia, Alzheimer’s disease, a history of falls, major depressive disorder, glaucoma, and a prior nasal bone fracture. On admission, the resident’s MDS showed a BIMS score of 3, indicating severely impaired cognition and a need for staff assistance with all ADLs. The admission fall assessment categorized the resident as “No Risk” with a score of 9.0, and a fall care plan was initiated with general interventions such as encouraging appropriate footwear, maintaining a safe environment, keeping the call light and commonly used items within reach, and PT/OT evaluation as ordered or PRN. The resident also had impaired communication related to confusion and a primary language of Arabic, contributing to a language barrier. Following admission, the resident experienced multiple falls and fall-related events, many of them at night and some unwitnessed. On one occasion, the resident was found on the floor after attempting to reposition in bed; on another, staff documented that the resident was “constantly sliding himself out of bed and onto floor.” A telehealth note described an unwitnessed change in elevation with the resident found on the bedroom floor. The IDT later identified a root cause that the resident dropped a book and attempted to pick it up, and the care plan was updated to include therapy assessment for assist bars to improve bed mobility and a reacher for hard-to-reach items. However, therapy records showed the resident was never assessed by PT/OT for these interventions. The resident continued to have unwitnessed falls, including in the common area, where staff noted agitation, yelling, and a language barrier that made it unclear what was bothering him. As falls continued, the facility’s response increasingly focused on psychotropic and anti-anxiety medications rather than documented, completed environmental or functional interventions. Orders were initiated and adjusted for Alprazolam (Xanax), Ativan, and Seroquel for anxiety, agitation, and behaviors, including scheduled and PRN dosing, while the resident continued to experience falls from bed and the floor, often while trying to reach items such as a phone charger. A concave mattress was added after repeated falls from bed, and the IDT documented plans such as requesting a longer phone cord and educating the family about fall safety and not leaving the resident alone when restless. The DON later confirmed that there was no documentation that the resident had been assessed by therapy for assist bars and a reacher, despite this being a documented care plan intervention. The DON also stated the resident was placed in the common area at night for increased supervision, even though a fall had occurred there as well, and could not provide further documentation of additional assessments. Ultimately, after a series of falls and ongoing agitation, the resident’s daughter requested transfer to the hospital due to concerns about frequent falls and care. EMS documentation noted altered mental status, difficulty determining baseline, and conflict between family and facility staff that delayed departure. In the emergency department, the resident was evaluated for generalized weakness, multiple falls, and foul-smelling urine. Imaging of the pelvis revealed a mildly displaced avulsion-type fracture of the left ischial tuberosity at the common hamstring origin. The final hospital impression included urinary tract infection, generalized weakness, and a left ischium fracture. The surveyors concluded that the facility failed to implement adequate/effective fall interventions and ensure consistent follow-up of fall interventions for this resident, resulting in a hospital transfer and identification of the left ischium fracture. The facility’s own fall management policy required identification of hazards and resident risk factors, implementation of interventions to minimize falls and injury, and provision of adequate supervision, assistive devices, and functional programs, coordinated by the DON/designee through an interdisciplinary process. Despite this policy, the record showed that key planned interventions, such as PT/OT assessment for assist bars and a reacher, were not carried out, and that the resident, who had severe cognitive impairment, communication barriers, and repeated falls, continued to experience falls without documented completion of the specified interventions and without clear evidence of effective adjustment of the fall prevention plan in response to the ongoing events.
Failure to Use Non-Pharmacological Interventions and Obtain Consent Before Extensive Psychotropic Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure necessary behavioral health care and services for a resident with dementia and Alzheimer’s disease, including consistent use of non-pharmacological interventions, appropriate indications for psychotropic medications, individualized behavioral care planning, and monitoring of behavioral health services. The resident was admitted with multiple diagnoses including dementia, Alzheimer’s disease, falls, major depressive disorder, and nasal bone fractures following a fall with syncope. An MDS assessment showed a BIMS score of 3, indicating severely impaired cognition and dependence on staff for all ADLs. A care plan addressing impaired communication related to confusion and a language barrier (primary language Arabic) was present, and a behavior care plan for actual behavior problems related to dementia with episodes of yelling and screaming was not initiated until ten days after admission. On multiple occasions, the NP and medical team ordered and adjusted psychotropic medications in response to reports of agitation, yelling, and screaming without consistent nursing documentation of the observed behaviors or of non-pharmacological interventions attempted beforehand. On one date, the NP documented increasing agitation, with reports from nursing staff and residents that the resident had been up all night screaming and yelling and that staff were unable to distract or redirect the behavior; Xanax 0.25 mg was added for anxiety, with an intervention to monitor non-pharmacological interventions. However, there was no corresponding nursing documentation of the agitation throughout the night and morning and no documentation of non-pharmacological interventions attempted. Over subsequent days, the NP discontinued Xanax and ordered Ativan 0.5 mg BID, a one-time dose of Seroquel 25 mg, and Seroquel 25 mg at bedtime, later increasing Seroquel to 50 mg in the evening and Xanax to 0.5 mg at bedtime, while continuing Zoloft and Remeron. The record showed no prior diagnosis of psychosis or anxiety, no documentation explaining why Ativan was added BID on a later date, and no documentation of behavioral descriptions or non-pharmacological interventions before administration of a one-time Ativan dose for reported anxiety and agitation. The facility also failed to obtain informed consent for multiple psychotropic medications and for behavioral health services, despite a policy requiring psychotropic informed consent before initiating or increasing such medications and a documented Statement of Capacity indicating the resident was incapable of making informed medical decisions, activating the daughter’s DPOA authority. A physician order for psychiatric services to evaluate and treat as indicated was present, but the record lacked evidence of behavioral health consultation or specialized mental health services arranged as referenced in the care plan. The behavior care plan, initiated several days after admission, included interventions such as administering medications as ordered, documenting behaviors and responses, using calm approaches, diversion, removal from situations, identifying underlying causes, and providing appropriate activities, but the record did not show consistent implementation or monitoring of these interventions. Interviews with the DSS and DON confirmed lack of involvement in behavioral planning, lack of consultation with behavioral health services, absence of team discussion prior to psychotropic use, and absence of behavioral monitoring and oversight of multiple psychotropic medications with similar classifications, with no further explanation or documentation provided by the end of the survey. Additionally, the facility did not implement interventions to monitor for adverse reactions or side effects of the antipsychotic and antianxiety medications administered, contrary to its Psychoactive Medication Management policy, which emphasized minimizing psychotropic use and using non-pharmacological interventions as the first choice. The care plan for potential fluctuations in mood referenced arranging specialized mental health services as indicated on the Level II assessment, but the record did not show that such services were arranged or utilized. The combination of missing behavior documentation, lack of non-pharmacological intervention records, absence of informed consent, delayed and insufficiently individualized care planning, and lack of monitoring for adverse effects collectively led to the cited deficiency for failing to provide necessary behavioral health care and services for this resident. Interviews further highlighted gaps in the facility’s behavioral health processes. The DSS, who started employment around the time of the resident’s stay, could not clearly identify the resident’s targeted behaviors beyond falls and attempts to get out of bed and reported no involvement in the behavioral plan of care or implementation of non-pharmacological interventions. The DSS also confirmed that behavioral health services were not consulted for the resident and acknowledged that the IDT should have met to discuss behavioral and medication needs and then approached the resident’s daughter for psychotropic medication consent. The DON identified the resident’s targeted behaviors as yelling out and being resistive to care and stated that the resident was being followed by the medical team but did not believe the resident had been referred to behavioral health services. The DON acknowledged concerns about multiple psychotropic administrations without documentation of prior non-pharmacological interventions, lack of oversight of multiple psychotropics of the same class, and lack of behavioral monitoring and management, with no additional documentation provided to address these issues.
Failure to Follow Professional Standards in Medication Reconciliation and Administration
Penalty
Summary
Staff failed to consistently follow nursing professional standards for two residents, resulting in medication reconciliation and administration errors. For one resident with multiple fractures, heart conditions, and recent surgeries, observations revealed that scheduled morning medications and as-needed pain medications were not administered at the ordered times. The resident reported significant pain and had not received any morning medications by late morning. Interviews with LPNs confirmed that medication passes were running late, and this was a regular occurrence due to insufficient staffing. Review of the electronic medical record and narcotic disposition book showed discrepancies in documentation, with pain medications not recorded as administered in the electronic system, though they were documented in the narcotic log. For another resident admitted for rehabilitation after a spinal cord injury and surgery, the facility failed to properly reconcile medication orders upon admission. The hospital discharge summary specified that Oxycodone should be administered as needed, but the medication was entered into the facility's system as a scheduled dose every four hours. As a result, nursing staff administered Oxycodone every four hours regardless of the resident's reported pain level, including when the resident reported no pain. The error persisted until it was identified during a review, and the order was not corrected to match the physician's intent for as-needed administration. Interviews with the unit manager, medical director, and DON confirmed that the medication reconciliation process was not properly followed, and nursing staff did not compare the physician's orders with the pharmacy label and the medication administration record. The facility's policy required licensed nurses to verify the accuracy and frequency of medication orders, but this was not done, leading to inappropriate medication administration and documentation errors for both residents.
Failure to Properly Label and Date Insulin Pens
Penalty
Summary
Surveyors observed that the facility failed to properly label and date opened insulin pens for two residents during a review of medication storage. Specifically, one resident's Lantus insulin pen, although labeled with their name, was found stored in a bag labeled for another resident. Additionally, six insulin pens were found on the medication cart without any indication of the date they were opened. During interviews conducted at the time of observation, nursing staff confirmed that insulin pens should be labeled for the correct resident and dated upon opening, and acknowledged that these practices were not followed. The staff also noted that the facility had recently transitioned from using insulin vials to insulin pens.
Failure to Assess, Monitor, and Document Catheter Care Leading to Adverse Outcomes
Penalty
Summary
The facility failed to accurately assess, monitor, and document catheter care for three residents who had indwelling urinary catheters, resulting in significant negative outcomes. In one case, a resident with a history of diabetes, neurogenic bladder, and recurrent UTIs experienced severe abdominal pain, distention, and lack of urine output. Despite repeated complaints from the resident and their family, nursing staff did not promptly assess or document the resident's condition, failed to monitor urine output, and did not document catheter care or replacement. The resident was not sent to the hospital until several hours after symptoms began, and upon arrival, was found to be in septic shock due to a UTI, ultimately leading to death. There was no documented order for the catheter, no record of medical necessity, and no documentation of urology consultations or follow-up on recommendations. For two additional residents with catheters, the facility did not document urine output or catheter care as required. One resident had a foley catheter with orders for daily care and monitoring, but there was no documentation of urine output or evidence that straight catheterization was attempted as ordered. Progress notes indicated abnormal urine characteristics, but lab orders were not consistently placed or followed up. The other resident, who was non-verbal and had a history of UTI and urinary retention, had inconsistent documentation regarding catheter care and monitoring. The care plan did not address catheter care, and the electronic record lacked specific documentation of catheter care or urine output, despite orders and care plan interventions indicating these should be monitored. Interviews with facility staff, including the DON and nurse practitioners, revealed a lack of clarity and consistency regarding protocols for catheter care, documentation, and monitoring. Staff were unable to explain why required documentation was missing or why care plan interventions were not followed. The facility's own policy required monitoring and documentation of catheter care and urine output, but these practices were not consistently implemented or recorded for the residents reviewed.
Incomplete and Inaccurate Electronic Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate electronic medical records for two residents, as evidenced by missing documentation of Activities of Daily Living (ADL) care and incomplete records regarding a resident's transfer and medication administration. One resident, who was alert and cognitively intact, reported not receiving a shower since admission and agreed their nails were long. Review of their clinical record showed no documentation of shower, bathing, or nail care in the electronic task records, nor was there any care plan documentation addressing these ADL needs. The Director of Nursing confirmed that a glitch prevented proper recording of these services and that the resident's preference for bed baths was not documented in the appropriate section. Another resident's record lacked critical information following an incident where the resident called 911 and was transferred to the hospital after making suicidal statements. The clinical record did not indicate the time of return to the facility, nor did it contain hospital or EMS records specifying the hospital destination or any accompanying documents. Additionally, the Medication Administration Record (MAR) showed that several medications were not administered on the day of the incident, with hold times noted but no further explanation or documentation regarding the missed doses. Interviews with nursing staff and the DON revealed a lack of recall regarding the resident's return time and medication administration, and the DON acknowledged that documents often do not return with residents from the emergency room. The facility's own policy requires that electronic medical records include comprehensive documentation such as physician orders, medication records, care plans, and scanned hospital documents, but these requirements were not met in the cases reviewed.
Deficient Food Safety Practices and Unsanitary Conditions in Kitchen
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety, as observed during a survey. On the morning of March 25th, four whole, foil-wrapped frozen turkey breasts were found in a sink basin with a thin stream of water running over one of them. By noon, the turkeys were still in the sink without running water. Dietary Staff CC indicated that the turkeys were being prepared for cooking the following day. This method of thawing does not comply with the 2017 FDA Food Code, which requires potentially hazardous food to be thawed under refrigeration or completely submerged under running water at a temperature of 70°F or below. Additionally, the facility did not utilize cooling logs, which are necessary to ensure that cooked potentially hazardous food is cooled within the required time and temperature parameters. Further observations revealed unsanitary conditions in the kitchen. The food prep counter next to the steam table and the counter where the microwave was stored were soiled with dried food spills and crumbs. Clean coffee mugs, glasses, and bowls were stored directly on these dirty surfaces. The facility also failed to maintain proper sanitation practices, as there were no red sanitizer buckets set up in the kitchen, and wiping cloths were found lying directly inside a dry sink basin. According to the FDA Food Code, wiping cloths should be held in a chemical sanitizer solution between uses to prevent contamination.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with dignity and respect, as evidenced by multiple incidents involving three residents. One resident, identified as R60, reported an incident where they were left unattended and in need of changing. When they called for assistance, a staff member responded in a disrespectful manner, telling them they lacked patience and dismissing their tears as fake. This incident occurred during a shift change, and the resident was left feeling disrespected and upset. Another resident, R52, expressed concerns about the lack of staff identification, as staff members were not wearing name tags. This made it difficult for residents to identify and address staff members properly, leading to confusion and a lack of trust. Observations confirmed that many staff members were not wearing name tags, and some had makeshift identifiers using tape, which was not a standard practice. A third resident, R318, and their family member reported that a staff member had an attitude and was rough during care, particularly when changing the resident's brief. This behavior was distressing to both the resident and their family member, who wished for gentler care. The family member reported these concerns to the facility's administration, highlighting the need for improved staff-resident interactions.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that grievances and concerns raised by residents during resident council meetings were promptly documented, investigated, tracked, and resolved. This deficiency was identified for two residents who participated in these meetings. During a group meeting, residents expressed that they were not informed about the plans to address the issues they raised, such as long wait times for call light responses and other ongoing concerns. The residents reported that facility staff would assure them that issues would be fixed, but no follow-up or resolution was communicated back to the resident council. A review of the resident council minutes from the previous six months revealed recurring concerns, including long wait times for call light responses, call lights being turned off without addressing the concern, and dietary preferences not being followed. Despite these issues being documented in the meeting minutes, the facility's Assistant Administrator and Regional Director of Operations admitted that there was no documentation of these concerns being addressed or resolved. No grievance forms or documentation of resolutions were provided by the end of the survey, indicating a lack of proper grievance handling and communication with the residents.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to ensure prompt response to call light requests for residents requiring assistance with activities of daily living. This deficiency was observed in four residents, including one who was left in a soiled brief for an extended period, raising concerns about potential infection. The resident, who had a history of stroke, COPD, diabetes, and urinary tract infections, reported that they had been left in a soiled brief since early morning despite multiple requests for assistance. Observations confirmed that staff entered the room, turned off the call light, and left without providing the necessary care, leaving the resident in discomfort and distress. Other residents also reported similar issues with delayed responses to call lights, with some resorting to yelling for help to avoid soiling themselves. These residents, who required assistance with daily living activities, expressed frustration over the lack of timely care, particularly during evening hours when management was not present. The clinical records of these residents indicated they had intact cognition and required staff assistance, yet they experienced significant delays in receiving care, highlighting a systemic issue in the facility's response to resident needs.
Failure to Implement Timely Interventions for Resident Safety
Penalty
Summary
The facility failed to implement appropriate interventions timely and consistently for two residents, resulting in potential risks for further falls, elopements, and avoidable accidents. One resident, who had severe cognitive impairment and a history of falls, was observed without a wanderguard despite being at risk for elopement. The resident's wheelchair lacked an anti-rollback device, and staff were unaware of the proper interventions required for fall prevention. The resident experienced multiple falls, including incidents in the bathroom, and staff failed to ensure the necessary safety measures were in place. Another resident sustained a skin tear during care due to a CNA not following the resident's instructions. The resident, who required assistance with most activities of daily living, reported that the CNA was in a hurry and did not listen to their request to use the shoulder instead of the arm during repositioning. The CNA's actions led to a skin tear on the resident's left forearm, which required medical attention and wound care. Interviews with facility staff, including an LPN, Unit Manager, and Assistant Director of Nursing, revealed a lack of awareness and monitoring of the required interventions for fall and accident prevention. The staff acknowledged the deficiencies and the need for follow-up, but the report highlights the facility's failure to ensure that ordered interventions were consistently implemented and monitored, leading to potential risks for the residents involved.
Infection Control and PPE Lapses
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple observations of staff not using appropriate Personal Protective Equipment (PPE) and not performing hand hygiene during medication administration. A Certified Nurse Assistant (CNA) entered the room of a resident on contact precautions for Clostridioides difficile (C. Diff) without donning PPE, despite facility policy requiring gown and gloves for such situations. The resident's care plan did not include contact precautions, and the CNA believed PPE was unnecessary since no direct care was provided. Another incident involved a resident under Enhanced Barrier Protection (EBP) where both a CNA and a Licensed Practical Nurse (LPN) failed to wear the required gown while performing various care tasks, including a skin assessment and handling a Percutaneous Endoscopic Gastrostomy (PEG) tube. This oversight occurred despite the presence of EBP signage and available PPE supplies, indicating a lapse in following established protocols for infection control. Additionally, during medication administration, an LPN was observed not performing hand hygiene between administering medications to different residents. This was acknowledged by the LPN, who admitted inconsistency in hand hygiene practices. The facility's policy mandates hand hygiene before and after medication preparation and administration, yet this was not adhered to, as evidenced by the observations of the LPN's actions.
Failure to Provide Appropriate Bed Accommodation
Penalty
Summary
The facility failed to accommodate a resident's need for an appropriate bed, leading to discomfort and potential skin issues. The resident, who was admitted with conditions including asthma, atrial fibrillation, anxiety, and depression, required maximal assistance with bed mobility and was dependent for toileting. Despite being cognitively intact, the resident expressed frustration over the inadequacy of their bariatric hospital bed, which was too short for their height of 5'7". This resulted in the resident frequently sliding down the bed and having to call nursing staff for repositioning, as their feet were constantly in contact with the wooden footboard. Observations revealed a large red area on the resident's left foot pad, indicating potential skin damage from the footboard contact. Despite the resident's complaints to the nursing staff and the administrator, no action was taken to provide a longer bed. Additionally, there was no documentation in the electronic medical record regarding the resident's skin condition or any follow-up actions. The acting Director of Nursing acknowledged the lack of documentation and the need for follow-up with the nursing and maintenance staff.
Failure to Administer Pain Medication Due to Reordering Lapse
Penalty
Summary
The facility failed to adhere to nursing standards of practice for medication administration, specifically for a resident identified as R7, who was not administered their prescribed Norco pain medication on the evenings of March 14 and 15, 2025. R7, who has a medical history including congestive heart failure, chronic kidney disease, and diabetes mellitus, reported during a resident council meeting that they had not received their pain medication on multiple occasions due to the facility running out of the medication. A review of R7's medical records confirmed the absence of Norco administration on the specified dates, with electronic medication administration record (EMAR) notes indicating that the medication was not available due to the need for a new prescription. The nurse manager, identified as NM D, acknowledged that the medication had run out and that a prescription was sent for a new delivery. However, the nurses failed to reorder the medication in a timely manner and did not utilize the backup supply system to administer the medication. The facility's process for ensuring timely medication administration, as outlined in their document titled 'Keys to Success to Receive STAT Medications Timely,' was not followed. This process includes reordering medications before they run out and using the backup supply system when necessary. The nurse manager confirmed that there was no documentation of the evening doses being administered from the backup supply, highlighting a lapse in following the established protocol for medication administration.
Failure to Implement Physician Orders for Edema Treatment
Penalty
Summary
The facility failed to transcribe and implement treatment orders as prescribed by the physician for a resident who was admitted for physical therapy following left shoulder surgery and had a history of hypertension and edema. The resident required diuretic therapy and was observed with swollen, shiny, and reddened lower extremities with serosanguineous drainage. Despite an order to apply compression stockings daily and wrap the legs with dry gauze, the resident reported that the stockings had not been applied all week, and observations confirmed the absence of stockings. The treatment administration record inaccurately documented the application of compression stockings, and the new order to wrap the legs was not processed due to incomplete scheduling details. The Assistant Director of Nursing acknowledged that the nursing staff should have reviewed the order completely, and treatments were missed because the frequency was not indicated. The facility's policy requires licensed nurses to verify that orders are complete, including accurate frequency, which was not adhered to in this case. The resident's condition was exacerbated by the lack of proper treatment, as evidenced by the worsening swelling and drainage from the legs. The ADON concurred that the situation was unacceptable and indicated that the issue would be addressed, although the nurse responsible for documenting the application was unavailable for an interview.
Inadequate Pressure Ulcer Care and Documentation Issues
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for two residents, R81 and R312. R81, who was admitted with multiple diagnoses including stroke, dementia, and quadriplegia, was found to have seven pressure ulcers, two of which were acquired in-house. Observations revealed improper positioning and inadequate offloading, contributing to the development of these ulcers. Additionally, there were inconsistencies in wound documentation, with duplicate records and discrepancies in wound descriptions, making it difficult to track the progression of R81's wounds. The facility also failed to document reasons for missing wound care treatments, which were noted on several occasions in March 2025. R312, admitted with conditions such as heart failure and a femur fracture, had an unstageable pressure ulcer on the left heel upon admission. Despite being cognitively intact, R312 experienced pain due to improper offloading of the heel, as reported by their family member. Observations confirmed that R312's heel was often positioned directly on the mattress, contrary to the care plan's requirements. There were also discrepancies in the documentation of R312's wound, with conflicting descriptions as a diabetic ulcer and a pressure ulcer, and a missing weekly wound care assessment note. The Director of Nursing acknowledged the concerns regarding both residents' care and documentation issues. The facility's policy on skin management was reviewed, but it lacked specific documentation requirements for pressure ulcers. The absence of a policy for pressure ulcer care and documentation further contributed to the deficiencies observed in the care provided to R81 and R312.
Failure to Monitor Resident's Weight Leads to Potential Malnutrition
Penalty
Summary
The facility failed to implement appropriate and consistent weight monitoring for a resident, resulting in the potential for unidentified weight loss and malnutrition. The resident, who was admitted for short-term skilled nursing and rehabilitation, had a history of COVID, high blood pressure, dizziness, depression, sleep apnea, and chronic lymphocytic leukemia. Upon admission, the resident's weight was recorded as 276.9 lbs, which was inconsistent with the discharge weight from the hospital of 259 lbs. Despite the family expressing concerns about the resident's lack of appetite and weight loss, the facility did not obtain an accurate admission weight or monitor the resident's weight throughout their stay. The resident's care plan included interventions for altered nutrition and hydration status, such as obtaining weekly weights for four weeks and then monthly if stable. However, the facility did not follow through with these interventions. The resident's electronic medical record did not contain any weekly weights or a reweight for the admission weight discrepancy. The Registered Dietician confirmed that there were no other weights recorded in the EMR and that the reweight and weekly weights were requested but not completed by nursing staff. Interviews with facility staff revealed a lack of adherence to the facility's weight management policy, which required reweights to be completed within 48-72 hours for significant weight variances. The Assistant Director of Nursing and Regional Clinical Consultant acknowledged the concerns with the resident's weight monitoring but did not provide a clear explanation for the failure to complete the necessary weight checks. The facility's document on weight management emphasized the importance of monitoring significant weight changes, but this was not effectively implemented for the resident in question.
Deficiency in Behavioral Care Management for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide comprehensive behavioral care management for a resident with severe cognitive impairment and a history of aggressive and wandering behaviors. The resident, diagnosed with Alzheimer's disease, dementia, and adjustment disorder, exhibited aggressive behaviors towards other residents and staff, resulting in two resident-to-resident incidents. Despite these behaviors, there was a lack of documented social work visits, supportive interventions, or follow-up actions to address the resident's needs, including communication barriers and grief over the recent death of their son. Observations revealed that the resident struggled to communicate their basic needs due to language barriers, as they primarily spoke Arabic. The staff, including the Certified Nurse Aide, attempted to communicate with the resident through gestures and pointing, but no effective communication tools, such as a communication board or interpreter, were consistently utilized. The Speech Language Pathologist later identified that the resident could benefit from a modified communication board with larger Arabic print, but this intervention was not implemented prior to the survey. The Social Worker acknowledged the absence of social services interventions and attributed it to an increasing facility census and staffing challenges. The facility's policy on social services emphasized the importance of addressing residents' psychosocial needs, including communication in their primary language and support during grief. However, these services were not adequately provided to the resident, contributing to the deficiency in behavioral care management.
Failure to Securely Store Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored safely and securely, as required by their policy. During observations, it was found that medications were left unsecured in the rooms of four residents. In the case of one resident, a bottle of Half Strength Dakin Solution was left on a cabinet next to the bed, despite the resident having severely impaired cognition. Another resident had a bottle of Wound Cleanser left on a dresser, also with severely impaired cognition. The Assistant Director of Nursing confirmed that no medications should be left in residents' rooms and should be locked in the medication or treatment carts. Additionally, a resident was found with several medications on their bedside table, including Voltaren Topical, Triad Paste, and saline nasal spray, without any orders for self-administration. Another resident had a bottle of wound cleanser left at their bedside after wound care was provided. The facility's policy clearly states that medications should not be left with residents unless they are approved for self-administration, which was not the case for these residents. These observations indicate a failure to adhere to the facility's medication storage policies, potentially compromising resident safety.
Failure to Complete Timely Laboratory Diagnostics
Penalty
Summary
The facility failed to ensure a laboratory diagnostic was completed in a timely manner as per the physician's order for a resident. The resident, who was admitted with diagnoses including heart failure and chronic kidney disease, had a physician's order for a STAT complete blood count (CBC) with differential and a comprehensive metabolic panel (CMP) on 2/25/25. Upon review of the medical record, it was found that the results for the CBC with differential were missing, although the CMP results were available. The nurse manager, upon reviewing the resident's record and laboratory portal, confirmed the absence of the CBC results and suggested it might have been an oversight with the lab requisition. No requisitions for the CBC were found, and the results were not provided by the end of the survey.
Failure to Provide Alternative Menus for Resident
Penalty
Summary
The facility failed to provide alternate menus and meal choices for a resident, identified as R312, who was admitted with diagnoses including heart failure, kidney failure, femur fracture, and malnutrition. Despite being cognitively intact and independent with eating, R312 expressed dissatisfaction with the taste of the food and reported not receiving an alternative menu despite multiple requests. The resident's family member, FM II, confirmed these concerns and resorted to bringing outside food to ensure R312 received adequate nutrition, which was crucial for their recovery and participation in therapy. The deficiency was further highlighted by the lack of awareness and communication among the facility staff regarding the availability of an alternative menu. Certified Nurse Aide EE and Dietary Aide Staff GG were unable to provide or confirm the existence of an alternative menu, and the Registered Dietician acknowledged the oversight in not providing the menu to residents who ate in their rooms. The facility's policy required alternate food items to be planned and posted along with the main scheduled meal, but this was not adhered to, leading to the resident's frustration and reliance on external food sources.
Failure to Provide Palatable Pureed Meals
Penalty
Summary
The facility failed to provide an attractive and palatable pureed meal to a resident, resulting in verbalized complaints and dissatisfaction with the meal service. The resident, who was admitted with a history of recurrent strokes, left-sided weakness, and dysphagia, required a PEG tube for nutrition and was identified at risk for weight loss. During an observation, the breakfast tray contained unrecognizable pureed food, and the meal ticket did not specify the foods provided, only indicating a regular Level 1 pureed diet with coffee and juice. The resident's family expressed frustration with the presentation and unrecognizable nature of the food, noting a previous instance of a green slimy substance that was unappealing. The family was unaware of the menu descriptions for pureed meals, as they had not been provided with a menu. The facility's policy, as explained by the Regional Dietician, did not require listing the foods on the meal tickets, which contributed to the dissatisfaction and lack of clarity regarding the meals served to the resident.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide scheduled showers for a resident, identified as R702, who was admitted for rehabilitation and continued medical care following a recurrent stroke. This stroke resulted in right-sided weakness, aphasia, and bowel and bladder incontinence. R702's medical history included diabetes, uterine cancer, and a left nephrectomy. Despite having intact cognition, as indicated by a Brief Interview for Mental Status score of 15/15, R702 expressed frustration and verbalized complaints about the lack of scheduled showers. The facility's policy stated that residents should receive showers or baths twice a week, as confirmed by both the Registered Nurse (RN) and the Director of Nursing (DON). However, a review of the Certified Nursing Assistants' (CNA) task documentation revealed that R702 had only received two showers since their admission, contrary to the facility's policy. This discrepancy was acknowledged by the DON when presented with the documentation, highlighting a failure in adhering to the established schedule for personal hygiene care.
Failure to Perform Physician-Ordered Dressing Changes for Pressure Ulcers
Penalty
Summary
The facility failed to ensure that physician-ordered dressing changes for pressure ulcers were performed for a resident, resulting in the potential for worsening of wounds and development of infections. The resident, who was observed with kerlix on their bilateral lower extremities, had multiple pressure ulcers, including stage IV ulcers on the sacrum, right hip, and right calf, as well as unstageable ulcers on the left calf and left heel. The resident's treatment administration record (TAR) showed that scheduled treatments for these ulcers were not documented as completed on several occasions, specifically on the day shift of 2/8/25, the night shift of 2/9/25, and the night shift of 2/11/25. Additionally, a treatment on the night shift of 2/6/25 was coded to refer to a nursing note, but no such note was found in the record. During an observation, the dressings on the resident were dated 2/11/25, with no shift time indicated, and the sacrum dressing appeared shadowed with wound drainage. The Director of Nursing confirmed that treatments should be performed according to physician's orders and that the Wound Care Nurse was responsible for ensuring their completion. The facility's policy on skin management, revised in 8/2024, states that residents with wounds and those at risk for skin compromise should be identified, evaluated, and provided appropriate treatment to promote prevention and healing. However, the failure to document and perform the necessary treatments as ordered indicates a lapse in adherence to this policy, potentially compromising the resident's care and recovery from pressure ulcers.
Failure to Implement Transmission-Based Precautions
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions for a resident, identified as R701, who was at risk of infection due to multiple medical conditions and devices. On the morning of February 12, 2025, it was observed that R701's room lacked signage indicating transmission-based precautions, and there were no personal protective equipment (PPE) supplies available outside or near the room. R701 was receiving tube feeding, had a urinary catheter, and was on intravenous antibiotics via a PICC line. The resident's clinical record revealed a history of osteomyelitis, sepsis, and multiple pressure ulcers, along with physician orders for enhanced barrier precautions due to the presence of multidrug-resistant organisms, wounds, and indwelling medical devices. During the same day, staff members, including Nurse 'B' and Unit Manager 'C', were observed providing care to R701 without wearing the appropriate PPE, such as gowns, despite the resident's need for enhanced barrier precautions. The Director of Nursing confirmed that R701 should have been on enhanced barrier precautions and that staff should have been wearing the appropriate PPE. The facility's policy on Enhanced Barrier Precautions was reviewed, which indicated the necessity of posting signage and using gloves and gowns during high-contact resident care for residents with wounds or indwelling medical devices.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to document and promptly resolve grievances reported by a resident, identified as R901, regarding incidents of improper care. The resident had alleged that a CNA refused to assist them with personal hygiene in the restroom and that a nurse made an inappropriate comment about their appearance in the hallway. Despite the facility administration being aware of these allegations, there was no documentation of any investigation or resolution of these grievances. The resident, R901, who had been admitted to the facility with diagnoses including dysthymic disorder, insomnia, and muscle weakness, required supervision and assistance with most activities of daily living. The resident reported feeling frustrated and humiliated by the incidents, which were allegedly witnessed by the facility's management. However, both the Administrator and the Director of Nursing confirmed that they were aware of the allegations but had not documented any grievance process or resolution. The facility's grievance policy mandates that all concerns should be documented and addressed promptly, with a follow-up to ensure resolution. However, in this case, the facility did not adhere to its own policy, as there was no documentation of the grievances or any investigation into the incidents involving the CNA and the nurse. This lack of documentation and follow-up constitutes a failure to honor the resident's right to voice grievances without discrimination or reprisal.
Improper Sanitation and Food Storage Procedures in Kitchen
Penalty
Summary
The facility failed to ensure proper sanitation and food storage procedures were followed in the kitchen, potentially affecting all 78 residents. During a kitchen tour, a large tub of ricotta cheese was found with the top ajar and no open date, despite being previously opened. Additionally, an insulin pen belonging to the Certified Dietary Manager (CDM) was stored on the food shelf, and an employee's cellphone was charging in the dry food storage area. Open and undated food items, such as pasta, butter, and grits, were also observed, along with wet spots on floors and countertops, and a glove on the floor. The cleaning schedule for the kitchen had not been implemented for December, with the last recorded cleaning on November 30, 2024. The CDM acknowledged responsibility for the cleaning schedule but had not yet implemented it for the current month. The facility's policy on kitchen sanitation did not provide guidance for the identified concerns. The Administrator confirmed that the CDM should not store personal items like insulin in the residents' refrigerator and that staff should not charge phones in the food storage area.
Delayed Response to Respiratory Distress
Penalty
Summary
The facility failed to timely identify, intervene, and notify the physician of a change in respiratory condition for a resident, resulting in delayed care and notification, ultimately requiring a hospital transfer. The resident, who was readmitted with a fracture to the neck of the right femur, experienced abnormal oxygen saturation levels of 81% and 85% on room air, which were not addressed by the staff. The facility's policy required consultation with the resident's practitioner upon a significant change in status, but this was not followed. The resident's condition was not identified or addressed until a nurse on the morning shift noticed the low oxygen saturation while administering medications. Despite the presence of monitoring devices above the resident beds, these were not operational, and the staff had to manually obtain vital signs. The nurse informed the nurse practitioner, who ordered a nebulizer treatment and applied oxygen, but this intervention occurred 11 hours after the initial abnormal oxygen saturation was noted. Interviews with facility staff revealed inconsistencies in the use and functionality of the monitoring devices, with the Director of Nursing stating that alerts were only sent to themselves and the Administrator. The devices did not monitor oxygenation levels, and the staff was not informed of the resident's low oxygen saturation level during shift changes. The resident was eventually transferred to the hospital at the family's request, and did not return to the facility.
Failure to Implement Wound Care and Antibiotic Treatment
Penalty
Summary
The facility failed to consistently implement and apply wound treatments as ordered by the practitioner, leading to delayed and omitted treatments for a resident with a pressure ulcer. The resident, who was readmitted to the facility with a fracture and required assistance for all activities of daily living, had a stage 3 pressure ulcer on the spine. Despite physician orders for specific wound care treatments, the facility did not apply the treatment on two occasions, and there was no documentation explaining the omissions. The wound worsened, developing a mild odor, and the deterioration was not identified by the facility staff but was noted by the Wound Practitioner during their rounds. Additionally, the facility failed to document clinical reasons for changing an antibiotic treatment and delayed or missed doses of both IV and oral antibiotics for the resident's wound infection. The resident was initially prescribed Keflex by the hospital, but the facility changed the antibiotic to Clindamycin without reviewing culture and sensitivity results. The change was based on information from the resident's daughter rather than clinical evidence. Furthermore, the resident missed several doses of the newly ordered Clindamycin, and there was no documentation explaining these omissions. The facility also failed to identify and report the worsening of the wound to the physician or practitioner. The resident's daughter had to notify the Wound Practitioner about the wound culture results and the worsening condition. The facility did not document the abnormal blood culture report or notify the physician, leading to further complications. The resident was eventually transferred to the hospital for a higher level of care due to the worsening wound and infection, and the facility did not provide adequate documentation or explanation for the transfer or the missed treatments.
Failure to Document Hospital Transfer for Resident
Penalty
Summary
The facility staff failed to ensure all required documentation for a resident's transfer to the hospital was recorded in the medical record. The resident, who was readmitted to the facility with a fracture to the neck of the right femur and had moderately impaired cognition, was transferred to the hospital without proper documentation of the transfer date or reason. A hospital transfer form indicated an abnormal X-ray and the need for IV antibiotics, but the medical record lacked documentation from the resident's physician or a non-physician practitioner justifying the transfer, as required by the facility's policy. Interviews conducted during the survey revealed that the Director of Nursing was unable to provide an explanation or additional documentation regarding the transfer. A Wound Practitioner mentioned that the resident's daughter had been informed of an abnormal microbiology report and preferred hospital treatment due to a delay in IV placement. However, the Wound Practitioner could not find documentation of this conversation in the medical record. The lack of documentation and explanation persisted through the end of the survey, highlighting a deficiency in the facility's adherence to transfer and discharge policies.
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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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