Regency At Waterford
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterford, Michigan.
- Location
- 1901 N Telegraph Rd, Waterford, Michigan 48328
- CMS Provider Number
- 235260
- Inspections on file
- 35
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Regency At Waterford during CMS and state inspections, most recent first.
A resident with multiple cardiac and renal comorbidities developed severe abdominal pain, nausea, and vomiting shortly after admission. Morning VS showed markedly elevated BP, tachycardia with irregular rhythm, and hypothermia, but there was no documented notification of the MD, NP, or PA despite the nurse later stating they had "reached out." By mid-afternoon, the resident continued to have significant pain, abnormal VS, and green emesis; a PA assessed the resident, noted poor condition, suspected sepsis, and ordered an abdominal X-ray and stat labs but did not send the resident to the ER at that time and was unaware of the earlier abnormal VS. That evening, the resident was found hyperventilating with tachycardia and tachypnea, and a critically high WBC was reported, after which the on-call provider ordered transfer to the ER for sepsis. The supervising physician and DON both stated the earlier VS should have been reported, and facility policies required practitioner notification for significant status changes and transfer when the resident’s needs could not be met in the facility.
A resident with severe cognitive impairment had their protected health information (PHI) inappropriately disclosed by a CNA to unauthorized family members, including during video chats at work and in conversations outside the facility. The resident's DPOA had not authorized these disclosures, and the CNA was terminated for violating confidentiality policies.
A newly hired LPN was allowed to begin orientation and training without completion of the required fingerprint-based background check. The personnel file lacked documentation of completed fingerprints, and the HR coordinator confirmed the appointment was missed and no fingerprints were on file, despite state law requiring this check before employment.
Two residents made allegations of abuse involving staff, including being struck with a washcloth or towel and having water thrown at them during an altercation. In both cases, staff members who were informed of the allegations did not promptly notify the abuse coordinator or the State Agency, resulting in significant delays in reporting and investigation, contrary to facility policy.
Multiple residents with intact cognition reported that meals were frequently served in Styrofoam containers, resulting in food that was not hot and lacked palatability. Residents stated this occurred several times per week and had been ongoing for months, with concerns raised repeatedly in Resident Council meetings. The Dietary Manager confirmed that staffing shortages led to the use of disposable containers, making it difficult to maintain proper food temperatures as required by facility policy.
The facility failed to ensure timely submission of progress notes for two residents. A progress note for a resident was entered after their death, and multiple notes for another resident were entered on the same day, indicating delays. The Director of Nursing confirmed the expectation for timely documentation, but the facility's policy did not address this requirement.
A resident with severe cognitive impairment and multiple health issues was found with a red raised lump on their head after returning from dialysis. The facility failed to report this injury of unknown origin to the Administrator and State Agency, as required by their policy. Despite hospital records indicating a suspected unwitnessed fall, the facility did not classify or report the incident properly.
The facility failed to maintain timely and accurate clinical documentation for a resident, resulting in a deficiency. A complaint revealed that staff entered late progress notes and documented in the clinical record after the resident's death. A nurse entered a late entry progress note seven days after the resident was found unresponsive, and documented medication outcomes after the resident's death. The DON confirmed that documentation should have been immediate, as per the facility's medical records management policy.
The facility failed to provide timely and appropriate pressure ulcer care for two residents, resulting in the development and worsening of pressure ulcers. One resident developed stage 3 pressure ulcers on the sacrum and left heel, and the right heel wound worsened due to delayed assessment and treatment. Another resident had a stage II pressure ulcer on the sacrum, but treatments were not initiated until 12 days after re-admission. The facility's policy on skin management was not followed, leading to these deficiencies.
The facility failed to provide a dignified dining experience for several residents, as observed during two dining sessions. Residents were left waiting for their meals while others received assistance, leading to expressions of hunger and dissatisfaction. Interviews with staff revealed that the protocol of serving residents needing 1:1 assistance first caused delays for others, conflicting with the facility's policy on resident dignity.
A resident with a history of stroke and dysphagia was observed multiple times with fluids placed out of reach, leading to potential dehydration. Despite being on a pureed diet with thickened liquids, the facility did not ensure fluids were accessible, and no policy was provided to address this issue.
The facility failed to provide necessary ADL assistance for two residents, leading to potential issues with nutrition and hygiene. One resident, non-verbal and cognitively impaired, had long nails with debris and consistently returned meal trays with unopened food, despite needing 1:1 feeding assistance. Another resident, with Alzheimer's and hemiplegia, struggled to eat without required 1:1 assistance and verbal cues. The facility's policies did not adequately address these care needs, contributing to the deficiencies.
A resident with epilepsy, traumatic brain injury, hallucinations, and dementia was found incapable of making medical decisions, yet the facility failed to secure legal representation. Despite a capacity determination, no legal decision maker was documented, and the facility delayed referring the case to a consulting company for guardianship. The facility eventually decided to proceed with filing for guardianship, despite the family's attorney's involvement.
A resident with a paralyzed right arm was supposed to be on a Maintenance Splint Program, but reported not wearing a splint for months and not receiving therapy, despite CNA documentation indicating otherwise. The order for the splint had been discontinued, yet staff continued to document its application, violating the facility's documentation policy.
The facility failed to follow proper infection control practices, particularly in the use of PPE and signage for transmission-based precautions. Staff were observed not wearing required PPE, such as N95 masks and gowns, when caring for residents on enhanced barrier precautions. Discrepancies were noted between signage and physician orders, and some residents did not have appropriate precautions initiated. Interviews revealed a lack of awareness among staff about the correct precautions needed, leading to potential infection spread.
Two residents were observed self-administering medications without being assessed for safety, contrary to facility policy. One resident with dementia was using a nebulizer treatment unsupervised, and another with end-stage renal disease had a nasal spray at their bedside. Both lacked documented assessments for self-administration, as confirmed by the DON.
A resident with severe cognitive impairment was found with pills scattered in their bed and on the floor, indicating a failure in medication administration standards. An LPN confirmed all medications were given and observed as taken, but the facility's policy requires nursing staff to ensure residents swallow their medications. The DON confirmed this policy, highlighting a lapse in adherence.
A resident with impaired cognition and mobility issues reported feeling bored and only watching TV, as the facility failed to provide diverse and engaging activities. The resident's care plan was outdated, and activities were limited to brief visits and TV, with no other options offered due to the resident's inability to get out of bed.
A facility failed to perform accurate clinical assessments and ensure interdisciplinary collaboration for a resident with a PEG tube, leading to recurrent infections and pain. Despite the resident no longer needing enteral feedings, the PEG tube remained, and the resident was not discussed in the At Risk Meeting. Additionally, the facility failed to administer prescribed ear drops to another resident, resulting in continued pain. The medication was unavailable, and the DON was unaware of how it was signed off as administered.
A resident with COPD was observed receiving oxygen at six liters per minute, contrary to the physician's order of three to four liters per minute to maintain oxygen saturation between 93-94%. The resident's oxygen levels consistently exceeded the recommended range, reaching up to 100%. The DON acknowledged the staff's failure to follow the physician's orders, and the facility's policy did not address this requirement.
A resident on hemodialysis did not have Physician orders for treatment or regular monitoring of their dialysis access site, as required by the facility's policy. The resident reported inconsistent assessments by nursing staff, and the Director of Nursing acknowledged the lack of necessary orders in the resident's records. This deficiency was identified through observations, interviews, and medical record reviews.
A resident was found to have duplicate orders for Montelukast Sodium, receiving 20mg daily due to an inappropriate order for hypertension. The DON confirmed the error after consulting with the NP, who indicated that one order should be discontinued.
The facility failed to label narcotic medications with resident identifiers and secure medication carts. An LPN found 30 syringes of Morphine Sulfate without resident names, and the DON confirmed they were returned to the pharmacy. Additionally, a medication cart with treatment creams was left unlocked and unattended in a common area.
A resident with dementia and legal blindness was not provided with necessary adaptive eating equipment during meals, despite facility policy requiring such provisions. The resident's care plan specified the need for a divided plate and a two-handed spouted cup, which were not provided on multiple occasions.
Failure to Notify Practitioner and Timely Transfer for Acute Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a practitioner of an acute change in condition and to ensure timely transfer to the ER for a resident who was newly admitted with diagnoses including heart failure, edema, chronic kidney disease, atrial fibrillation, high blood pressure, and muscle wasting/atrophy. Shortly after admission, the resident developed extreme abdominal pain with nausea and vomiting. On the morning in question, vital signs documented at 9:27 AM by a nurse showed a blood pressure of 178/105, heart rate of 125 with an irregular rhythm, and a temperature of 94.8°F. The nurse later stated they were “pretty sure” they reached out to the NP or PA, but the clinical record contained no indication that the MD, NP, or PA had been notified of these abnormal vital signs. In the afternoon, another nurse documented at 2:38 PM a blood pressure of 101/86, heart rate of 133 with an irregular rhythm, and temperature of 96.6°F, with a pain score of 7/10 at 2:44 PM. A progress note at 2:39 PM indicated the PA assessed the resident at bedside with the daughters present, noting abdominal pain and 10 cc of green emesis, and ordered an abdominal X-ray and stat labs for abdominal pain and nausea. The PA later reported the resident was in “poor condition,” lying flat in bed with a damp towel on the chest, complaining of left upper quadrant abdominal pain, and stated they suspected sepsis, ordering the X-ray and stat labs but choosing to wait for results before sending the resident to the ER. The PA also stated they had not been made aware of, nor reviewed, the earlier abnormal vital signs from that morning. That evening, a nurse documented that at approximately 6:30 PM the resident was observed hyperventilating, with vital signs of 154/78, heart rate 120 bpm, and respiratory rate 32/min. While the nurse was on the phone with the on-call prescriber to report “sepsis like symptoms,” another nurse received a call from the lab reporting a critically high WBC of 31,700, which was communicated to the provider, who then ordered transfer to the ER for sepsis. The supervising physician later stated that the morning vital signs should have been reported and that, had they been contacted, they might have started fluids and probably would have sent the resident to the ER. The DON agreed that the morning blood pressure, heart rate, and temperature were a concern and should have been reported, and acknowledged that the PA waited to see if ordered interventions would work before sending the resident out. The facility’s policies on Notification of Change and Transfer and Discharge require practitioner notification for significant changes in status and transfer when the resident’s needs cannot be met in the facility. The resident’s death certificate listed sepsis and pneumatosis intestine as the causes of death.
Failure to Maintain Resident PHI Confidentiality
Penalty
Summary
A facility failed to maintain the privacy and confidentiality of a resident's protected health information (PHI) for one of two residents reviewed. The resident in question had diagnoses including Alzheimer's disease, heart disease, and a history of lung cancer, and was assessed as having severely impaired cognition and being incapable of making informed medical decisions. A complaint was filed alleging that a facility employee disclosed the resident's diagnosis and personal information to other family members without authorization. The Durable Power of Attorney (DPOA) for the resident reported that a Certified Nursing Assistant (CNA) had video chatted with her cousin while at work, during which the cousin could see the resident and other residents. Additionally, the CNA disclosed to another family member at a store that the resident was not doing well and was expected to pass soon. The DPOA confirmed that she had not given permission for the CNA to share this information and specifically wanted to inform the resident's sister herself. Review of facility records showed that the CNA was no longer employed at the facility, having been terminated for disclosing confidential and privileged information to a family member not authorized to receive it. The facility's policy defined health information and disclosure, and the administrator confirmed that all employees were educated on HIPAA requirements. However, the incident demonstrated that the resident's PHI was shared inappropriately with unauthorized individuals, violating the facility's policy and federal privacy regulations.
Failure to Complete Required Background Check Prior to Staff Employment
Penalty
Summary
The facility failed to implement its abuse prevention policy by not ensuring a complete background check, including fingerprinting, was performed for a newly hired LPN. The personnel file for the LPN showed that while a fingerprint appointment was scheduled, there was no documentation that the fingerprinting was actually completed. The LPN began orientation and training at the facility and participated in several training days without the required fingerprint-based criminal history check being finalized. During interviews, the Human Resources coordinator confirmed that the LPN did not attend the scheduled fingerprint appointment and that no fingerprints were on file. The coordinator stated that they tracked and followed up on the process weekly but did not have evidence of completed fingerprints for the LPN. The administrator was made aware of the issue and acknowledged the concern. State law requires that fingerprint-based background checks be completed before employment for individuals with direct resident access, and the facility did not retain verification of compliance for this staff member.
Failure to Timely Report Allegations of Abuse to Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse involving two residents to the abuse coordinator and the State Agency. In the first incident, a resident informed a family member that a staff member had thrown a washcloth or towel at them. The family member reported this to the charge nurse, but the charge nurse did not promptly notify the abuse coordinator. As a result, the facility did not notify the State Agency or initiate an investigation until approximately 64 hours after the allegation was first reported to staff. In the second incident, a resident with a history of paranoid schizophrenia, diabetes, and acute kidney failure, and who had recently been hospitalized for aggressive behavior, was involved in an altercation with a staff member. The resident alleged that a staff member threw water at them during an argument about medication administration. Multiple staff interviews confirmed that the resident was agitated and that water was involved, but the incident was not reported to the abuse coordinator or investigated at the time. The administrator and staff were unaware of the abuse allegation until it was brought to their attention by the surveyor several days later. Facility policy requires that all allegations of abuse be immediately reported, thoroughly investigated, and documented by the administrator, and that appropriate authorities be notified. In both cases, staff members who were aware of the allegations did not follow these procedures, resulting in delayed reporting and investigation of the alleged abuse.
Meals Not Served at Palatable Temperatures Due to Use of Disposable Containers
Penalty
Summary
The facility failed to ensure that meals were enjoyable and served at palatable temperatures, as required, due to the use of disposable Styrofoam containers for meal service. Surveyors observed that breakfast and lunch meals were being served in Styrofoam boxes, and multiple residents reported that the food was not hot and did not taste good when served in these containers. The use of disposable containers was observed to occur multiple times per week, affecting the palatability and temperature of the food. Three long-term residents, all with intact cognition as indicated by their BIMS scores, were interviewed and confirmed ongoing dissatisfaction with the temperature and taste of meals served in Styrofoam containers. One resident, who was vegetarian and ate fish, stated they had stopped eating facility food and relied on food brought by family due to the poor quality and temperature of meals. Another resident, who was receiving supplemental oxygen, reported that food was not hot and did not taste right when served in disposable boxes. The Resident Council president also confirmed that the issue had been raised multiple times in council meetings, with several residents expressing similar concerns. The Dietary Manager acknowledged that staffing shortages led to the use of Styrofoam containers, particularly during breakfast and dinner when staff called off. The manager admitted that maintaining appropriate food temperatures was difficult with disposable containers. Facility documentation required hot foods to be held above 135°F and cold foods below 41°F at the point of service, but the use of Styrofoam containers and staffing issues interfered with compliance. The administrator was made aware of the ongoing concerns and the frequency of the issue, as well as the repeated reports from the Resident Council.
Failure to Ensure Timely Submission of Progress Notes
Penalty
Summary
The facility failed to ensure timely submission of physician or physician extender progress notes for two residents, R901 and R902. For R901, a progress note by Nurse Practitioner (NP) 'C' was entered into the record after the resident's death, indicating a delay in documentation. For R902, multiple progress notes were created and entered into the record by NP 'C' on the same day, suggesting a lack of timely documentation for each visit. An interview with the facility's Director of Nursing confirmed that the expectation was for progress notes to be entered in a timely manner. However, the facility's policy on Physician Services did not address the timely entry of progress notes into the record.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, identified as R903, to the Administrator and the State Agency. R903, who was severely cognitively impaired and required extensive assistance with most Activities of Daily Living, was admitted with diagnoses including end-stage renal failure and heart disease. On a specific date, a nurse noted a red raised lump on the left side of R903's head after the resident returned from dialysis. The resident was unable to explain the cause of the injury and was sent to the hospital for observation. Hospital records indicated a suspected unwitnessed fall, but the facility stated there was no fall, and the resident was not found on the ground. Despite the injury being classified as an injury of unknown source, it was not reported to the Abuse Coordinator/Administrator or the State Agency. Interviews with facility staff, including Nurse D, the Director of Nursing (DON), and the Abuse Coordinator, revealed that the injury was not reported as required by the facility's Abuse Prohibition Policy. The policy mandates that staff immediately report incidents of abuse and suspected abuse, including injuries of unknown source, to the Administrator and DON. The policy also requires notification of the resident's representative and any State or Federal agencies per state guidelines. The failure to report the injury of unknown origin was a deficiency identified during the survey, as the facility did not adhere to its own policy and state reporting requirements.
Failure to Maintain Timely and Accurate Clinical Documentation
Penalty
Summary
The facility failed to ensure clinical documentation met professional standards for a resident, leading to a deficiency. A complaint was received by the State Agency alleging that staff entered late progress notes and documented in the clinical record after the resident's death. A review of the resident's clinical record revealed a late entry progress note for a specific date and time, which was entered into the record seven days later by a nurse. The note indicated that the resident was observed unresponsive in bed with no pulse or respirations, and that the hospice nurse, physician, and family were notified. Additionally, the nurse documented the effective outcome of as-needed pain and anti-anxiety medications at a time after the documented death of the resident. An interview with the facility's Director of Nursing confirmed that the note regarding the resident's death should have been entered into the record immediately, not several days later. The facility's policy on medical records management requires that records be complete, accurately documented, and maintained in accordance with professional standards and legal requirements.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely and appropriate pressure ulcer care for two residents, resulting in the development and worsening of pressure ulcers. Resident 903 was admitted with a history of right-sided stroke and was noted to have a wound on the right heel and redness to the coccyx/sacral area upon re-admission. Despite an order for evaluation by a wound care practitioner on the day of re-admission, the resident was not assessed until 20 days later. During this period, the resident's condition worsened, developing a stage 3 pressure ulcer on the sacrum and left heel, and the right heel wound also worsened. The delay in assessment and treatment was attributed to the absence of the wound care nurse and a change in wound care nurse practitioners. Resident 902 was admitted with a facility-acquired stage II pressure ulcer on the sacrum. Upon re-admission, the resident's nursing admission assessment noted an open area on the sacrum, but no treatments were implemented until 12 days later. The facility's wound care nurse confirmed that there was no evidence of treatments being initiated upon re-admission. This delay in treatment was contrary to the facility's policy, which mandates the identification and implementation of interventions to prevent and treat pressure injuries. Interviews with the facility's wound care nurse and the Director of Nursing revealed awareness of the delays in assessment and treatment. The Director of Nursing acknowledged the family's concerns about the lack of heel protector boots on Resident 903, despite their presence in the room. The facility's policy on skin management emphasizes the importance of timely interventions to prevent and heal pressure injuries, which was not adhered to in these cases.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for several residents, as observed during two separate dining observations. On the first day, residents were seen waiting for their meals while others were being assisted with eating. Some residents expressed hunger and noted that delays in receiving food were common. The final food trays were served significantly later than when the dining began. On the second day, similar observations were made, with residents again waiting for their meals while others received assistance. Residents expressed their hunger and desire to eat, but their meals were delayed. Interviews with the Registered Dietician and Dietary Manager revealed that the facility's protocol was to serve meals to residents needing 1:1 assistance first, which resulted in delays for other residents. The facility's policy on resident dignity and personal privacy emphasizes providing care that respects and enhances each resident's dignity and self-worth. However, the observed dining practices did not align with this policy, as residents were left waiting and watching others eat, which compromised their dignity and self-determination.
Failure to Provide Accessible Fluids for Resident
Penalty
Summary
The facility failed to ensure that water and other fluids were available and accessible for a resident, resulting in the potential for thirst and complications from dehydration. On multiple occasions, the resident was observed in their bed with their lunch tray, which included a pureed meal and two magic cup supplements. However, two full cups of thickened orange juice were placed across the room on a dresser, out of the resident's reach, and the staff member who set up the tray did not move the juices within reach. Additionally, no water was observed to be provided within the resident's reach. The resident's clinical record indicated they had been readmitted to the facility with diagnoses including stroke, dysphagia, hemiplegia, and vascular dementia, and were on a regular diet with pureed texture and honey thickened liquids. Despite these needs, the facility's Director of Nursing acknowledged that fluids should have been within the resident's reach, but no policy on accommodation of needs or water within reach was provided by the end of the survey.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, resulting in potential issues related to nutrition and personal hygiene. Resident 39, who is non-verbal and severely cognitively impaired, was observed with long fingernails and dark debris under the nail beds over several days. Additionally, Resident 39's meal trays were consistently returned with unopened food items, despite the resident's care plan indicating a need for 1:1 assistance with eating. The facility's documentation inaccurately recorded the resident's meal consumption as 'Refused,' despite the resident's inability to verbally refuse food. Resident 98, who has Alzheimer's disease, protein-calorie malnutrition, and hemiplegia, was observed struggling to eat without the required 1:1 assistance and verbal cues as indicated in their care plan. On multiple occasions, Resident 98 was left to eat independently, despite their documented need for assistance due to cognitive and physical impairments. The facility's failure to provide the necessary support during meals was confirmed by the registered dietician, who acknowledged that staff should have been assisting Resident 98. The facility's policies on personal hygiene and meal service were reviewed, but the provided policy did not address the specific ADL care required for residents. The meal service policy indicated that residents should receive appropriate assistance during meals, which was not adhered to in the cases of Residents 39 and 98. This lack of adherence to care plans and facility policies contributed to the deficiencies observed during the survey.
Failure to Secure Legal Representation for Incapacitated Resident
Penalty
Summary
The facility failed to advocate for legal representation for a resident, identified as R107, who was deemed incapable of making informed medical decisions due to conditions including epilepsy, traumatic brain injury, hallucinations, and dementia. Despite a Statement of Capacity dated March 21, 2023, indicating R107's inability to make medical decisions, the facility did not have any documents showing a legal decision maker for R107. An interview with Social Services Staff 'K' revealed that the family had retained an attorney who was allegedly preventing the facility's consulting company from proceeding with obtaining guardianship, although no explanation was provided as to how the attorney was preventing the petition process. The facility's social services staff provided a timeline indicating that R107 was referred to the consulting company on November 6, 2023, which was eight months after the capacity determination. The timeline also noted that the facility decided to move forward with filing for guardianship on June 11, 2024, despite the family's attorney's involvement. The facility's Social Worker Job Description included the responsibility of facilitating the appointment of a responsible party as needed, highlighting a lapse in fulfilling this essential function for R107.
Inaccurate Medical Records for Resident's Splint Program
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, identified as R74, who was observed lying in bed and reported being unable to stand due to paralysis in the right arm. The resident, who had been at the facility for about two years, was supposed to be on a Maintenance Splint Program that required the application of a right hand splint for up to four hours daily, along with monitoring skin integrity and performing passive range of motion (PROM) exercises. However, the resident reported not having worn a splint for several months and not receiving any therapy, despite CNA staff documentation indicating that the splint had been applied daily from 5/14/24 through 6/11/24, except for one day. Upon review, it was found that the order for the splint had been discontinued on or about 8/10/23, yet CNA staff continued to document its application. The Unit Manager Nurse confirmed the absence of a current order for the splint and acknowledged that CNAs should not record services that were not provided. The facility's policy on documentation emphasized the importance of accurate and truthful record-keeping, highlighting that false entries are considered willful acts of falsification. This discrepancy between the resident's care and the documentation reflects a failure to adhere to the facility's documentation standards.
Infection Control Deficiencies in PPE and Precaution Signage
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, particularly concerning transmission-based precautions (TBP) and contact precautions for several residents. Observations revealed that staff did not consistently follow the required protocols for personal protective equipment (PPE) when entering rooms of residents on enhanced barrier precautions (EBP) and contact/droplet precautions. For instance, staff were observed entering rooms without donning N95 masks or eye protection, despite signage indicating these were necessary. Additionally, there were discrepancies between the signage and the actual physician orders, as seen with residents who had signs for contact/droplet precautions but only had orders for EBP. Several residents were affected by these lapses in infection control. One resident, who was on dialysis, did not have appropriate signage indicating the need for EBP, and staff reportedly did not wear gowns during care. Another resident with a PEG tube had their dressing changed by an LPN who failed to follow EBP by not wearing a gown, even after being reminded. Furthermore, a resident with a catheter was mistakenly placed on EBP due to a lack of awareness about their condition of impetigo, which required contact precautions instead. Interviews with staff, including a Certified Nurse Aide and the Director of Nursing (DON), highlighted a lack of awareness and understanding of the correct precautions needed for specific residents. The DON acknowledged that certain precautions were not correctly implemented, such as the unnecessary contact/droplet precaution signage and the failure to initiate EBP for a resident upon admission. These deficiencies indicate a systemic issue in the facility's infection control practices, potentially leading to the spread of infections among residents.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents, R12 and R43, were assessed for the safe self-administration of medications. R12, who has diagnoses including Dementia with mood disturbance and mild cognitive impairment, was observed self-administering a nebulizer solution treatment without any nursing supervision. A review of R12's medical records, including the physician orders and comprehensive care plan, did not show any assessment for the safe self-administration of the nebulizer treatment. R12's BIMS score indicated moderately impaired cognition, which further necessitates a formal assessment before allowing self-administration of medication. Similarly, R43, who has diagnoses including end-stage renal disease and congestive heart failure, was found with a fluticasone nasal spray on their bedside table, which they had been using without any formal assessment for self-administration. R43's medical records also lacked any indication of an assessment for safe self-administration of the nasal spray. The facility's policy requires a self-administration evaluation to be completed prior to allowing residents to self-administer medications, which was not adhered to in these cases. The Director of Nursing confirmed that these residents should not have been self-administering medications without an assessment.
Failure in Medication Administration Standards
Penalty
Summary
The facility failed to ensure that nursing services met professional standards for medication administration for a resident with severe cognitive impairment. The resident, who was admitted with hospice services and had a history of COPD, atrial fibrillation, hypertension, heart disease, bladder pain, anxiety, and dementia, was found with multiple pills scattered in their bed and on the floor. The resident was unable to recall if the medications were given that morning, indicating a lapse in proper medication administration and monitoring. An LPN confirmed that all medications were given and observed as taken, but the presence of pills in the resident's environment suggested otherwise. The facility's policy on medication administration requires that nursing staff observe residents swallowing their medications and prohibits leaving medications with residents to self-administer. The Director of Nursing confirmed that medications should be observed by nursing staff to ensure they are taken, highlighting a failure to adhere to the facility's medication administration policy.
Failure to Provide Engaging Activities for Resident
Penalty
Summary
The facility failed to provide meaningful, diverse, and engaging activities for a resident, identified as R74, who was observed to be lying in bed and reported feeling bored all the time. R74, who had been at the facility for about two years, was diagnosed with vascular dementia, depression, and type II diabetes, and had a BIMS score indicating impaired cognition. The resident required extensive assistance with most Activities of Daily Living and was unable to stand, with a paralyzed right arm and non-functional legs. Despite these conditions, the resident reported that they were only watching TV and had not been offered any other activities, and they could not see the activity schedule due to vision problems. The resident's care plan, which had not been updated since March 2022, indicated a preference for independent or in-room activities and included interventions such as offering outdoor activities and providing an activities calendar. However, there was no documentation of activities being provided or refused, and no notes from the Activity Director were found in the resident's clinical record. Interviews with the Activity Director and an Activity Assistant revealed that the resident did not get out of bed, and the activities provided were limited to brief 1:1 visits, music/radio, and TV/movies, with no other activities offered due to the resident's inability to get out of bed. The facility's policy on activities emphasized the importance of providing an ongoing program based on individual evaluations and care plans, but this was not reflected in the services provided to R74.
Deficiencies in Clinical Assessment and Medication Administration
Penalty
Summary
The facility failed to perform ongoing, accurate clinical assessments and ensure interdisciplinary team collaboration for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The resident, who had severe cognitive impairment and a history of stroke, was observed with a PEG tube site that had significant bloody drainage and purulent discharge. Despite the resident no longer requiring enteral feedings and tolerating a regular diet, the PEG tube remained in place, leading to recurrent infections and pain at the site. The interdisciplinary team, including wound care and infection control, did not collaborate effectively to address the resident's condition, and the resident was not discussed in the facility's At Risk Meeting. Another deficiency involved the facility's failure to administer prescribed ear drops to a resident experiencing ear pain. The resident, who had moderately impaired cognition, reported not receiving the ear drops ordered by the medical doctor. The medication was documented as unavailable for several days, and the resident continued to experience pain. The Director of Nursing was unaware of how the medication was signed off as administered when it was not available on the medication cart. These deficiencies highlight a lack of proper communication and coordination among the facility's staff, leading to inadequate care and prolonged discomfort for the residents involved. The facility's policies and procedures for ensuring timely and accurate medical treatment were not effectively implemented, resulting in negative outcomes for the residents.
Failure to Adhere to Physician-Ordered Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident received the correct physician-ordered oxygen therapy, resulting in elevated blood oxygen levels. The resident, who had a history of chronic obstructive pulmonary disease (COPD), pneumonia, and dependence on oxygen, was observed receiving oxygen at six liters per minute via nasal cannula, despite a physician's order specifying three to four liters per minute to maintain oxygen saturation levels between 93-94%. Observations over several days confirmed that the oxygen concentrator was set at six liters per minute, and the resident's documented oxygen saturation levels consistently exceeded the recommended range, reaching as high as 100%. The Director of Nursing acknowledged that staff should have adhered to the physician's orders, and the facility's policy for oxygen therapy did not address the necessity of following physician orders for appropriate oxygen delivery.
Failure to Ensure Physician Orders for Dialysis Care
Penalty
Summary
The facility failed to ensure that Physician orders were in place for the treatment, monitoring, and assessment of a resident who was on hemodialysis. The resident, identified as R43, was observed on multiple occasions and reported that the nursing staff did not regularly assess their dialysis access site. Additionally, the medical record review revealed that there were no Physician orders for dialysis treatment or monitoring of the access site for potential complications such as thrill, bruit, stenosis, or thrombosis. The facility's policy required such orders and regular assessments, but these were not documented in R43's records. The Director of Nursing (DON) confirmed that residents on dialysis should have Physician orders and regular monitoring of the access site, but was unable to explain why R43's records lacked these orders. The facility's policy on hemodialysis outlined specific procedures for assessing the dialysis access site for various complications, yet these procedures were not followed for R43. This deficiency was identified through observations, interviews, and a review of the resident's medical records, highlighting a failure in the facility's adherence to its own policies regarding dialysis care.
Duplicate Medication Order for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, resulting in a deficiency. A review of the medical records revealed that a resident was receiving duplicate orders for Montelukast Sodium, with one order for allergies and another incorrectly for hypertension, leading to a total daily dosage of 20mg. The Director of Nursing (DON) confirmed that hypertension was not an appropriate indication for Montelukast and acknowledged the duplicate order after consulting with the nurse practitioner, who stated that one of the orders should be discontinued.
Improper Labeling and Security of Medications
Penalty
Summary
The facility failed to properly label and secure narcotic medications and medication carts. During an observation, a medication cart was found with 30 syringes of Morphine Sulfate, each labeled with the dosage but lacking resident identifiers. The LPN acknowledged the absence of identifiers and indicated the need to contact the pharmacy. The Director of Nursing confirmed that the pharmacy sent the medications without names and that they were returned. Additionally, a medication cart containing various wound and treatment creams was observed unlocked and unattended in a common area, posing a security risk.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive equipment and assistive devices for a resident, identified as R17, who required them for eating. On two separate occasions, R17 was observed in the dining room attempting to eat lunch without the necessary adaptive equipment specified on their meal ticket. The meal ticket indicated that R17 should have been provided with a divided plate and a two-handed spouted cup, but these items were not provided. R17's medical record indicated that they had diagnoses including dementia and legal blindness, and their care plan included the use of adaptive equipment to assist with eating. The facility's policy on adaptive equipment requires the dietary manager or dietitian to assess residents for the need for adaptive equipment and to ensure that such equipment is provided if needed. However, despite these requirements, R17 was not provided with the necessary adaptive devices during meals. The facility's failure to adhere to its own policy and provide the required equipment resulted in a deficiency in the care provided to R17.
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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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