Regency Heights-detroit
Inspection history, citations, penalties and survey trends for this long-term care facility in Detroit, Michigan.
- Location
- 19100 West Seven Mile Road, Detroit, Michigan 48219
- CMS Provider Number
- 235452
- Inspections on file
- 23
- Latest survey
- May 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Regency Heights-detroit during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain an adequate supply of emergency food as outlined in its disaster menus. Key non-perishable items such as assorted 100% juices, high protein breakfast bars, shelf-stable milk, and canned potatoes were missing and could not be substituted with other foods on hand. Additional items listed on the disaster menus were also not available, though some could potentially be substituted in an emergency. Facility leadership acknowledged the deficiency during interviews.
Surveyors identified failures in food safety and sanitation, including improper cooling and storage of cooked foods, missing caulking at a handwashing sink, unsanitary handling and storage of an ice scoop, and lack of proper labeling for food in a resident refrigerator. Staff were unaware of correct procedures, and facility policy for labeling and checking food was not followed.
Surveyors found that the facility's walk-in freezer was not consistently maintaining proper temperatures, with repeated observations of soft ice cream and a door that did not seal correctly, allowing cold air to escape. The Dietary Manager and NHA were aware of the issue but had not taken steps to address it prior to the survey, resulting in a deficiency related to equipment maintenance and food safety standards.
Two residents were found using wheelchairs with damaged and frayed armrests, missing padding, and exposed foam, resulting in discomfort and surfaces that could not be properly cleaned. Staff confirmed that the wheelchairs should have been repaired or replaced, and that the condition should have been reported by nursing.
Two residents did not receive their full prescribed medications when an LPN prepared and stacked medication cups for multiple residents at once, omitting some medications and not following the facility's policy for safe medication administration. Both the nurse manager and DON confirmed this practice was not in line with professional standards.
A dependent resident with severe cognitive impairment and multiple health conditions was repeatedly observed with excessively long and discolored fingernails, despite documentation indicating daily ADL care including nail care. Staff confirmed the need for nail trimming and cleaning, and facility policy required such grooming for residents needing extensive assistance, but the care was not provided as required.
A resident with chronic kidney disease and epilepsy did not receive a physician-ordered Keppra blood level lab draw due to an incorrectly entered order by a nurse. The lab test was not completed, and there was no documentation or notification to the physician regarding the missed test, despite facility policy requiring adherence to physician orders.
A resident with a history of myocardial infarction and intact cognition had a signed DNR order and corresponding physician notes, but the EMR information page incorrectly listed the resident as Full Code after a hospital readmission. Nursing staff and the DON confirmed that care decisions are based on the EMR code status, and the error was due to an incorrect update, resulting in the resident's wishes not being accurately reflected in the record.
A resident with severe cognitive impairment was diagnosed with pneumonia, and an antibiotic was prescribed, but the Resident Representative was not notified of this significant change in health status. The facility's policy requires such notifications, but it was not followed in this case.
A resident with severe cognitive impairment developed an unstageable pressure ulcer due to the facility's failure to implement necessary interventions such as a specialty mattress and regular repositioning. Despite being identified as at moderate risk, the resident was often observed without appropriate pressure-relieving devices, and staff showed a lack of knowledge regarding the use of these devices.
The facility failed to maintain sanitary conditions in the kitchen, leading to potential cross-contamination of food. Observations revealed staff handling food without gloves, not performing hand hygiene after glove removal, and not following proper food handling techniques, despite existing policies emphasizing these practices.
The facility failed to notify a resident's family of a change in condition and subsequent hospital transfer. The resident's room was found empty, and family members were unaware of the transfer until they inquired at the nurse's station. A review of the EHR confirmed no documentation of family notification, and the DON acknowledged the lapse in following the facility's 'Transfer and Discharge' policy.
The facility failed to address residents' concerns about call light response times, leading to dissatisfaction and unmet needs among 13 out of 20 residents. Despite the concerns being raised in a resident council meeting, the issue was not documented or communicated to the appropriate staff, and the Administrator was unaware of the problem.
The facility failed to ensure accurate transfer information was communicated to the receiving hospital for a resident. The resident's EHR indicated a transfer due to abnormal labs, but the 'Transfer Form' inaccurately documented 'shortness of breath' based on outdated information. Both the NP and DON confirmed the inaccuracy, and the responsible nurse had copied information from a previous form.
The facility failed to apply splinting devices for two residents, leading to potential increased joint contracture and pain. One resident with severe cognitive impairment and hemiplegia was observed without a hand roll, and another resident with contractures and severe cognitive impairment was observed without elbow braces. The LPN admitted to not applying the splints despite documenting otherwise, and the DON confirmed the lack of a restorative nurse or aide.
The facility failed to date a respiratory water bag for a resident with a tracheostomy, leading to a deficiency in providing safe and appropriate respiratory care. The resident, who has chronic respiratory failure and severe cognitive impairment, had a water bag for oxygen humidification observed multiple times without a date label. Interviews with an LPN and the DON confirmed the requirement for dating the water bag.
The facility failed to maintain accurate documentation in the EHR and MAR for three residents, leading to incomplete medical records and inadequate care delivery. An LPN admitted to not applying prescribed braces and hand rolls despite documenting otherwise, and a transfer form inaccurately stated the reason for a resident's hospital transfer.
The facility failed to ensure that two residents were provided with influenza vaccination and education, resulting in the potential for the development and spread of influenza. The Infection Preventionist reported that these residents did not have documentation of a current influenza immunization or refusal. The DON confirmed that both residents should have been educated and offered the influenza vaccine, as per the facility's policy.
A resident receiving palliative care was found expired on the floor with an injury to the back of her head. The facility failed to document an Accident and Incident (A&I) report or conduct a thorough investigation as required by its policy. The Safety Coordinator and DON acknowledged the lack of documentation and investigation, leading to a deficiency in compliance with state regulations.
Inadequate Emergency Food Supply
Penalty
Summary
The facility failed to ensure an adequate supply of emergency food was available, as required by their emergency planning recommendations. During an observation and interview with the Dietary Manager, it was found that the facility's disaster menus for three days included specific non-perishable items such as assorted 100% juices, high protein breakfast bars, shelf-stable milk, and canned potatoes, which were not present in the facility's emergency food supply and could not be substituted with other foods on hand. Additional items listed on the disaster menus, including green beans, chicken and dumplings, carrots, apricots, ham, green peas, pulled chicken, mixed vegetables, assorted sodas, and stewed tomatoes, were also missing but could potentially be substituted in an emergency. The Nursing Home Administrator confirmed that the facility should have the correct amount of food for three days, acknowledging the deficiency when interviewed. No additional documentation or information was provided by facility leadership during the exit conference.
Deficiencies in Food Safety, Sanitation, and Labeling Practices
Penalty
Summary
Surveyors observed multiple deficiencies in food safety and sanitation practices within the facility. Cooked, potentially hazardous foods such as meatballs, corned beef, baked beans, and diced potatoes were stored in the walk-in cooler without completion of required cooling logs, and staff responsible for storing these foods were unaware of proper cooling procedures. Additionally, the caulking around the handwashing sink was missing, which the Dietary Manager acknowledged could allow bacteria to grow if water seeped behind the sink. An ice scoop was observed being placed directly back into the ice chest after use, rather than being stored in a designated bin, raising concerns about cross-contamination. The staff member handling the ice scoop was not wearing gloves and admitted the scoop should have been stored outside the ice chest. Further inspection of a resident refrigerator on the first floor revealed several food items, including partially eaten stir fry, a carbonated beverage, bread, sliced salami, sliced cheese, and salad, that were not labeled with resident names or dates. Facility policy requires all food brought in to be checked, sealed, labeled with content, resident name, date received, and an expiration date, but these procedures were not followed. These findings were confirmed through interviews with the Dietary Manager and review of facility policy and the FDA Food Code.
Failure to Maintain Walk-In Freezer in Proper Working Order
Penalty
Summary
Surveyors observed that the facility failed to maintain the walk-in freezer in proper working order, as evidenced by repeated findings of an internal temperature of 9°F and soft, not fully frozen, ice cream during multiple visits. The freezer door did not seal properly, with a visible gap allowing cold air to escape. The Dietary Manager acknowledged awareness of the door issue but did not consider it a concern since meat remained frozen, and stated that a new freezer was needed. The Nursing Home Administrator confirmed knowledge of the faulty freezer door but had not initiated replacement prior to the survey. These findings were supported by reference to the 2013 FDA Food Code, which requires frozen foods to be maintained in a frozen state and equipment to be kept in proper repair.
Failure to Maintain Safe and Clean Wheelchairs for Two Residents
Penalty
Summary
The facility failed to maintain the wheelchairs of two residents in a safe and comfortable condition. Observations revealed that one resident's wheelchair had both armrests in disrepair, with one armrest severely frayed and only partially covered, and the other missing padding entirely, exposing bare metal. The back section of the same wheelchair was also partially missing its covering, exposing the foam underneath. Another resident's wheelchair had both armrests split and frayed, with exposed padding, and the resident reported that the armrests sometimes caused discomfort. Interviews with facility staff confirmed that managers were responsible for identifying wheelchair repairs and contacting maintenance, and that replacement pads were available. The Therapy Manager and DON both acknowledged that the damaged armrests and back support should have been replaced, noting that the cracked surfaces could not be adequately cleaned and could cause skin issues. Clinical records indicated that both residents used wheelchairs for mobility and had diagnoses that included mobility impairments. The DON stated that the condition of the wheelchairs should have been reported and addressed by nursing staff.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards of practice for two residents. An LPN was observed preparing medication cups for two different residents at the same time, stacking the cups on the medication cart, and only including packaged medications while omitting floor stock medications. The LPN stated that this was done to save time and acknowledged that it did not align with the facility's medication administration policy. Upon inspection, it was found that neither resident had all of their prescribed 9:00 AM medications in their respective cups, with several medications missing for both residents. Interviews with the nurse manager and the DON confirmed that the facility's policy requires preparing and administering medications for one resident at a time, immediately prior to administration, and then signing them out. Both staff members expressed that the observed practice was unsafe and not in accordance with professional standards or facility policy. The facility's policy, last revised in October 2023, specifically states that medications are to be administered in an accurate, safe, timely, and sanitary manner, and that safe preparation practices must be followed.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a dependent resident, who required maximum assistance for activities of daily living (ADLs) due to severe cognitive impairment and diagnoses including dementia and protein-calorie malnutrition, was observed on multiple occasions to have excessively long and discolored fingernails. The resident's nails extended one fourth to one third of an inch beyond the fingertips and appeared light brownish in color. Despite being non-responsive to interview questions, the resident's condition was confirmed by both a certified nurse assistant (CNA) and a unit nurse manager/licensed practical nurse (LPN), who acknowledged that the nails needed to be trimmed and cleaned. A review of the resident's electronic medical record (EMR) indicated that daily ADL care, including nail care, was documented as provided over the past thirty days, with no significant behavioral resistance noted. The facility's policy required grooming tasks such as nail trimming for residents needing extensive assistance. However, the observed state of the resident's nails and staff interviews revealed that appropriate nail care was not performed as required, despite documentation suggesting otherwise.
Failure to Complete Physician-Ordered Keppra Level Lab Draw
Penalty
Summary
A physician ordered a Keppra (levetiracetam) blood level to be drawn for a resident with chronic kidney disease and epilepsy who had been readmitted to the facility. Review of the resident's electronic health record (EHR) showed that the Keppra level was ordered but not completed, and there were no progress notes indicating that the blood draw had occurred. The resident had no documented seizure activity during this period. The Director of Nursing (DON) confirmed upon review that the Keppra level had not been drawn, attributing the failure to an incorrectly entered order by a nurse. The facility did not have a specific policy for lab or blood draws, but did have a policy for following physician's orders, which was not adhered to in this case. As a result, the physician was unaware that the ordered lab test had not been completed.
Failure to Accurately Document Resident Code Status in EMR
Penalty
Summary
The facility failed to accurately document a resident's code status in the electronic medical record (EMR), resulting in a discrepancy between the resident's documented wishes and the information available to staff. The resident, who had a history of myocardial infarction and demonstrated intact cognition, had a signed Do-Not-Resuscitate (DNR) order on file, which was also reflected in multiple physician progress notes. However, the EMR information page incorrectly listed the resident as Full Code following a hospital readmission, due to an error made during the update of the resident's status. Interviews with nursing staff, including LPNs and the Unit Manager, confirmed that staff rely on the EMR information page to determine code status in emergency situations. The Director of Nursing also acknowledged that the EMR was marked inaccurately and that the resident should have remained a DNR according to their wishes. The facility's policy recognizes the right of residents to self-determination and to have advance directives respected, but this was not upheld in this instance due to the documentation error.
Failure to Notify Resident Representative of Pneumonia Diagnosis
Penalty
Summary
The facility failed to notify the Resident Representative (RR) of a diagnosis of pneumonia and a physician's order for an antibiotic for a resident. The resident, who had severe cognitive impairment and was diagnosed with Alzheimer's disease, dysphagia, and adult failure to thrive, experienced a change in condition on January 15, 2025. The resident was noted to feel hot to the touch, and a physician recommended a chest x-ray. The RR was notified of this initial change. However, later that day, after the chest x-ray results indicated pneumonia and an order for Doxycycline was made, the RR was not informed of the new diagnosis and treatment plan. During an interview, the Director of Nursing (DON) acknowledged awareness of the pneumonia diagnosis and the antibiotic prescription but admitted that the RR had not been notified. The facility's policy on Notification of Change requires informing the resident, consulting with the resident's practitioner, and notifying the RR of significant changes in the resident's health status. This policy was not followed in this instance, as the RR was not informed of the significant change in the resident's health status and the new treatment plan.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement necessary interventions to prevent pressure ulcers for a resident, resulting in the development of an unstageable pressure ulcer on the resident's left hip. The resident, who had severe cognitive impairment and required substantial assistance to move, was observed multiple times without appropriate pressure-relieving devices such as a specialty mattress or foam wedges. Despite being identified as at moderate risk for pressure ulcers, the resident was often seen in a wheelchair or on a standard mattress without the necessary support to prevent skin breakdown. The resident's electronic health record indicated no open skin areas upon admission, but a dark circle on the left hip was noted later, which progressed to an unstageable pressure ulcer. The care plan for the resident included the use of a pressure reduction mattress and regular turning and repositioning, but these interventions were not consistently implemented. Observations revealed that the resident's mattress was a standard one, and there were no positioning devices in the room, even after the pressure ulcer was identified. Interviews with staff, including the RN, LPN, and DON, highlighted a lack of knowledge and communication regarding the ordering and use of specialty mattresses. The DON eventually replaced the standard mattress with an LTC 105 mattress, suitable for stage 3 or 4 pressure ulcers, but this was done hours after the deficiency was noted. The facility's skin management policy and mattress grid were not followed, leading to the resident's condition worsening.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, leading to an increased potential for cross-contamination of food and foodborne illness. During an observation, Dietary Cook B was seen touching a piece of cooked pork loin with bare hands while checking its temperature and then placing it back in the pan without wearing gloves. Additionally, Assistant Cook C removed gloves and did not perform hand hygiene before writing down temperatures in a book. Dietary Cook B was also observed removing gloves, touching serving utensils, and searching for buns without performing hand hygiene. Similarly, Dietary Aide E removed gloves, entered the walk-in cooler, and exited with ranch in hand without washing hands, prompting CDM D to instruct her to wash her hands. The Certified Dietary Manager (CDM) D confirmed that staff should wash their hands after removing gloves and change gloves between tasks. The facility's policies, including the U.S. Public Health Service 2017 Food Code and the facility's own Food Handling and Production policy, emphasize the importance of hand hygiene and using proper food handling techniques to prevent foodborne illness. Despite these policies, the staff's actions did not align with the required standards, leading to the observed deficiencies in maintaining sanitary conditions in the kitchen.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to immediately notify the family of a resident's change in condition and subsequent transfer to the hospital. On the morning of 04/04/24, it was observed that the resident's room was empty, and an LPN confirmed that the resident had been sent to the hospital before her shift started. Later that morning, a family member arrived at the nurse's station inquiring about the resident's whereabouts and was informed by another LPN that the resident had been transferred to the hospital. The family member expressed frustration, stating that they had not been notified and that this had happened multiple times before. A phone call to another family member confirmed that they were also unaware of the transfer. A review of the resident's Electronic Health Record (EHR) showed no progress notes or documentation indicating that the family had been notified of the change in condition or transfer to the hospital. The Nurse Practitioner who ordered the transfer due to abnormal lab results requiring hospital treatment confirmed that there were no progress notes in the EHR and could not verify if the family had been notified. The Director of Nursing (DON) also reviewed the EHR and confirmed the lack of documentation regarding the transfer and family notification. According to the facility's 'Transfer and Discharge' policy, notice of an emergency transfer should be provided to the resident and their representative as soon as practicable, which was not adhered to in this case.
Failure to Address Call Light Response Time Concerns
Penalty
Summary
The facility failed to respond to residents' concerns about staff call light response times, leading to dissatisfaction and unmet needs among 13 out of 20 residents. During a resident council meeting, multiple residents expressed their dissatisfaction with the call light response times, with one resident mentioning a wait time of three and a half hours. Despite these concerns being raised, the facility did not take appropriate action to address them, as evidenced by the lack of documentation in the pink forms used for tracking such issues. The Activities Director indicated that the process for addressing resident council concerns involves filling out a pink form and following up with a department manager. However, none of the forms reviewed addressed the issue of call light response times, and the concerns mentioned in the resident council meeting had not been communicated. Additionally, the Administrator was unaware of the residents' concerns about call light response times, indicating a breakdown in communication and follow-up within the facility's grievance process.
Failure to Communicate Accurate Transfer Information
Penalty
Summary
The facility failed to ensure accurate information for transfer was communicated to the receiving hospital for one resident reviewed for discharges and transfers. On the morning of 04/04/24, a Licensed Practical Nurse (LPN) reported that the resident was sent to the hospital before her shift started and she was unaware of the circumstances requiring the transfer. The resident's Electronic Health Record (EHR) indicated an order for transfer due to abnormal labs, but the 'Transfer Form' inaccurately documented the reason as 'shortness of breath' based on outdated information from a previous transfer form dated 3/12/24. There was no corresponding progress note to provide additional medical information to the receiving hospital. Upon review, the Nurse Practitioner (NP) confirmed that the 'Transfer Form' was inaccurate and that the resident did not have shortness of breath. The NP was in the process of documenting a progress note at the time of the review. The Director of Nursing (DON) also confirmed the inaccuracy of the 'Transfer Form' and noted that the nurse responsible had copied information from a previous form without explanation. The facility's 'Transfer and Discharge' policy requires a transfer form, a list of medications, and a copy of care plan goals to be sent to the receiving hospital, along with documentation of the hospital transfer in the medical record, which was not followed in this instance.
Failure to Apply Splinting Devices
Penalty
Summary
The facility failed to apply splinting devices for two residents, resulting in the potential for increased joint contracture, loss of range of motion, and increased pain. One resident was observed multiple times with a clenched left hand and no hand roll or towel roll in place, despite the Electronic Health Record (EHR) and Medication Administration Record (MAR) indicating that a hand roll should be applied during the day. This resident had diagnoses including Alzheimer's disease, diffuse traumatic brain injury, and hemiplegia and hemiparesis on the left side, with severe cognitive impairment and dependency for activities of daily living (ADLs). Another resident was observed multiple times with bent elbows and elbow braces not worn, despite the EHR and MAR indicating that elbow braces should be applied daily. This resident had diagnoses including chronic respiratory failure, contractures to both elbows, and traumatic brain injury, with severe cognitive impairment and dependency for ADLs. The Licensed Practical Nurse (LPN) admitted to not applying the splints but documenting that they were applied. The Director of Nursing (DON) confirmed that there was no restorative nurse or aide, and that floor staff were responsible for applying the splints, which were not applied as ordered by the physician.
Failure to Date Respiratory Water Bag
Penalty
Summary
The facility failed to date a respiratory water bag for a resident with a tracheostomy, leading to a deficiency in providing safe and appropriate respiratory care. On multiple occasions, the resident's water bag for tracheostomy oxygen humidification was observed without a date label. Interviews with an LPN and the Director of Nursing confirmed that the water bag should be dated to ensure proper monitoring and replacement. The resident, who has chronic respiratory failure, a tracheostomy, contractures in both elbows, and a traumatic brain injury, was admitted to the facility with severe cognitive impairment. The manufacturer's guidelines for the water bag recommend replacing it every 60 days or earlier if it becomes discolored.
Inaccurate Documentation in EHR and MAR
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the Electronic Health Record (EHR) for three residents, resulting in inaccurate and incomplete medical records and inadequate care delivery. For one resident, the Medication Administration Record (MAR) inaccurately documented the application of elbow braces, which the Licensed Practical Nurse (LPN) admitted to not applying. Similarly, another resident's MAR inaccurately documented the application of a hand roll, which the same LPN also admitted to not applying. The Director of Nursing (DON) confirmed that the documentation was incorrect and incomplete, which could affect the residents' care and treatments. Another resident was transferred to the hospital for abnormal labs, but the transfer form inaccurately documented the reason for the transfer as shortness of breath, which was not the case. The Nurse Practitioner (NP) confirmed the inaccuracy and noted the absence of a corresponding progress note to provide accurate medical information to the receiving hospital. The DON confirmed that the transfer form was inaccurate and that the nurse had copied information from a previous transfer form without proper verification.
Failure to Provide Influenza Vaccination and Education
Penalty
Summary
The facility failed to ensure that two residents, R126 and R87, were provided with influenza vaccination and education, resulting in the potential for the development and spread of influenza among vulnerable residents. On 4/5/2024 at 11:00 AM, the Infection Preventionist (IP) reported that these residents did not have documentation of a current influenza immunization or refusal. R126, admitted with diagnoses of respiratory failure and heart failure, and R87, admitted with diagnoses of urinary tract infection and dementia, both lacked documentation indicating that the influenza vaccine was offered or contraindicated. The Director of Nursing (DON) confirmed that both residents should have been educated and offered the influenza vaccine. The facility's policy, revised on 1/11/22, mandates that residents be offered immunization against influenza annually, with the program running from early October through March 31st, and every admission screened and given the vaccine if indicated after receiving education regarding the vaccine.
Failure to Investigate Injury and Death
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin and unexpected death of a resident receiving palliative care. The resident was found expired on the floor with an injury to the back of her head. There was no Accident and Incident (A&I) report or total body assessment documented in the resident's Electronic Health Record (EHR). The Safety Coordinator and the Director of Nursing (DON) acknowledged the lack of documentation and investigation, despite the facility's policy requiring thorough investigation and documentation of such incidents. The DON admitted to starting an investigation but did not document it until later, which was not in compliance with the facility's Abuse Prohibition Policy. The facility's policy mandates that allegations of abuse, neglect, or adverse events be thoroughly investigated and documented. However, in this case, the facility did not follow its policy, as there was no immediate documentation or investigation into the resident's death and injury. The DON and the Safety Coordinator could not confirm if the resident had an injury to the back of her head, highlighting the lack of a proper investigation. This failure to document and investigate the incident led to a deficiency in the facility's compliance with its own policies and state regulations.
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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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