Regency Manor Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Utica, Michigan.
- Location
- 7700 Mcclellan Street, Utica, Michigan 48317
- CMS Provider Number
- 235617
- Inspections on file
- 23
- Latest survey
- July 18, 2025
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Regency Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified that multiple residents with complex medical conditions and on multiple daily medications, including psychotropics and antipsychotics, did not have required monthly medication regimen reviews (MRRs) documented by a pharmacist for at least 12 months. Despite requests, staff were unable to provide or locate the missing MRRs in the electronic medical record, indicating a failure to follow facility policy and regulatory requirements.
Surveyors found that food items brought in from outside for residents were not dated and the resident refrigerator's temperature was not consistently monitored. The refrigerator lacked a visible thermometer, the temperature log was outdated, and several food containers were undated, contrary to facility policy.
A strong and persistent urine odor was observed throughout the facility, including entryways and hallways, over multiple days. The carpets, which covered all hallways, had no documented cleaning schedule or recent cleaning records, and staff were unable to provide a policy for carpet maintenance or ensuring a home-like environment. This resulted in a failure to maintain a clean and comfortable setting for all residents, staff, and visitors.
The facility lacked a site-specific Water Management Plan, with missing risk assessments, system diagrams, and monitoring for Legionella, and staff were unfamiliar with the program. Additionally, an LPN failed to use required PPE during a high-contact activity for a resident on Enhanced Barrier Precautions, and staff interviews revealed uncertainty about PPE requirements.
The facility did not ensure eight hours of RN coverage within a 24-hour period on multiple days, with gaps in coverage documented over several months. The DON/NHA and a Unit Manager RN shared responsibility for staffing, but frequent call-ins and staffing instability contributed to the deficiency. Documentation of staffing policies and RN coverage was not provided during the survey.
Two multi-use ophthalmic medications for single resident use were found opened in a medication cart without being labeled with the date they were opened. An LPN, the unit manager, and the DON all confirmed that such medications should be dated when opened, but this was not done. The facility was also unable to provide a policy on medication storage and labeling when requested.
A resident with dementia and impaired cognition, known to be at risk for elopement, exited the facility unsupervised through a dining room door with a malfunctioning alarm. Staff only became aware of the resident's absence after being alerted by a neighbor, and the resident was found walking down the street. The door was last checked several days prior, and maintenance was unaware of the alarm issue. Supervision was interrupted during shift change, and the exit area was only partially secured.
The facility failed to maintain a homelike environment in resident showers and ensure backflow protection for the ice machine. Observations showed black mold in the ice machine drain and shower rooms, along with lime build-up on a sink faucet. The Nursing Home Administrator acknowledged these issues.
A resident was transported from a medical appointment in a manner that violated their rights to dignity and safety. The facility's van was late, and the driver had two children without car seats, who hit the resident during the ride. The driver also exhibited inappropriate behavior by cursing at the children and a doctor's office manager. The Nursing Home Administrator was informed but did not follow up with the resident or their family.
A facility failed to consistently apply a wound vac for a resident with a history of osteomyelitis and pressure ulcers. After a doctor's appointment, the resident returned without the wound vac because the facility did not send the necessary supplies. The wound vac was found with dried blood and was not reapplied as per physician orders. The MAR showed multiple instances of non-application, and the facility's policy on wound treatment was not followed.
The facility failed to document showers for two dependent residents, leading to incomplete medical records. One resident, with conditions requiring extensive assistance, had only three shower records over 60 days, with two refusals. Another resident, needing assistance due to a brain injury, had no shower documentation. The Nursing Home Administrator acknowledged the documentation gap.
The facility failed to provide evidence of a comprehensive infection prevention and control program, affecting all 32 residents. The NHA reported that the DON, who was on vacation, had the necessary documentation. The Infection Control Program book lacked documentation of comprehensive surveillance and data analysis, despite the facility's policy requiring oversight by an Infection Preventionist.
The facility failed to ensure that the QAPI committee met quarterly and included required members, affecting all 33 residents. Several meetings were missing, and those that occurred lacked key members such as the NHA and DON. The current NHA, who started in May 2024, could not explain the deficiencies.
The facility failed to implement enhanced barrier precautions for two residents with indwelling urinary catheters and skin impairments, and lacked proper infection control surveillance documentation. Additionally, the facility did not have an active water management plan to reduce the risk of Legionella and other pathogens.
The facility failed to conduct regular care conferences for four residents, leading to a deficiency in the development and implementation of person-centered care plans. Residents with various diagnoses, including high blood pressure, stroke, schizoaffective disorder, and dementia, had missing or delayed care conferences, contrary to the facility's policy.
The facility failed to follow up and document physician notification of pharmacy recommendations for four residents. Despite identified pharmacy concerns, actual reports were not received, and it could not be determined if the concerns were addressed. The DON and NHA acknowledged the expectation for timely completion and follow-up of pharmacy reviews.
The facility failed to maintain effective contact with a resident's representative, despite multiple attempts by staff over several months. The resident, with significant medical conditions, experienced multiple hospitalizations, and the legal guardian was suspended without new representation being obtained.
The facility failed to develop an elopement baseline care plan for a resident with severe cognitive impairment and a high risk of elopement. Despite being assessed as at risk, the resident's care plan lacked necessary goals and interventions, leading to an incident where the resident exited the building and was found outside, although unharmed. Interviews with staff confirmed that baseline care plans should be completed within 48 hours of admission, but this was not done in this case.
A facility failed to implement care plan interventions for a resident on psychotropic medication. Despite the resident's diagnoses and moderate cognitive impairment, there was no care plan addressing psychiatric behaviors or behavior related to the medications. The DON confirmed that alternative measures should be tried and documented before administering medication, but this was not done.
A resident with Alzheimer's Disease, Heart Disease, and Hypertension was transferred to another facility without a discharge summary or recapitulation of stay. The Nursing Home Administrator confirmed the absence of the required documentation, which is mandated by the facility's Discharge Planning Process policy.
The facility failed to follow a hospital recommendation, a physician's order, and follow up on a dental consultation for two residents. One resident did not receive a recommended MRI and neurology follow-up, while another did not receive a referral for necessary dental extractions.
A resident with severe cognitive impairment and multiple medical conditions experienced 12 falls over several months due to the facility's failure to supervise and assess the effectiveness of fall prevention interventions. Despite having a care plan in place, the interventions were not revised following each fall, nor was their effectiveness documented, leading to repeated falls and hospital transfers.
The facility failed to maintain orders for indwelling catheter care for a resident with multiple medical conditions, including dementia and obstructive uropathy. Despite observations of the resident with an intact catheter, orders for catheter care and changes were discontinued and not renewed, as confirmed by the DON.
The facility failed to ensure that PRN psychotropic medications had adequate indications for use and a stop date for a resident with multiple diagnoses, including Schizophrenia and Diabetes Type 2. The DON and two LPNs confirmed that orders for antipsychotic medications should include a reason and a stop date, but this was not done.
The facility failed to control urine odors and ensure adequate ventilation, as observed by surveyors. A strong urine odor was noted in specific rooms and common areas, and the bathroom vent in one room was found to be ineffective. Despite efforts to clean, the odor persisted, and the facility's policy on maintaining a safe and homelike environment was not effectively implemented.
The facility failed to maintain safe and sanitary kitchen conditions, with issues such as rusted cans, frost build-up in freezers, a malfunctioning refrigerator, and general uncleanliness. The dietary manager acknowledged the problems but did not take immediate corrective action, and the DON confirmed that the facility did not adhere to its own food safety policies.
The facility failed to ensure a clean and safe environment, affecting all residents. Multiple rooms had various cleanliness and maintenance issues, and one resident's tube feeding equipment was significantly soiled. The DON acknowledged these deficiencies.
The facility failed to ensure handrails were firmly mounted in the upper hallway, affecting five residents. Several handrails were observed to be loose and easily jiggled when pressure was applied. These concerns were acknowledged by the maintenance supervisor and reviewed with the DON, who confirmed the need for a safe environment. A policy related to handrail maintenance was requested but not received before the survey exit.
Failure to Document Monthly Medication Regimen Reviews by Pharmacist
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed and documented monthly medication regimen reviews (MRRs) for nine residents over a 12-month period, as required by facility policy and federal regulations. Surveyors found that for each of the nine residents reviewed, there was no documentation of MRRs in the electronic medical record, despite these residents having complex medical histories and being prescribed multiple daily medications, including psychotropics, antipsychotics, antiseizure medications, opioids, and insulin. The absence of MRR documentation was confirmed through record reviews and interviews with facility staff. Specific examples included residents with diagnoses such as schizophrenia, bipolar disorder, depression, dementia, diabetes, and heart disease, all of whom were receiving multiple medications daily. For instance, one resident with anxiety, depression, diabetes, and stroke was administered 13 medications daily, including antiseizure and antipsychotic drugs, with no MRRs documented for the past year. Another resident with schizoaffective disorder, bipolar disorder, and hypertension was also found to have no MRRs documented, despite being on 12 daily medications, including antipsychotics and antihypertensives. When surveyors requested the missing MRRs from staff, including the infection control preventionist and corporate consultant, staff indicated that the reviews may not have been scanned into the medical record and would investigate further. However, no MRRs were provided or uploaded into the electronic medical record before the survey concluded. The facility's policy required pharmaceutical services to meet each resident's needs and comply with state and federal requirements, but the lack of MRR documentation demonstrated a failure to follow these procedures.
Failure to Date Resident Food and Monitor Refrigerator Temperature
Penalty
Summary
Surveyors observed that the facility failed to ensure that food items brought in from outside for residents were properly dated and that the temperature of the resident refrigerator was consistently monitored. During inspection, the resident refrigerator in the break room was found without a visible thermometer, and the temperature log had not been updated for nearly three weeks. Additionally, three food containers inside the refrigerator were undated. When questioned, the Dietary Manager indicated that responsibility for monitoring the refrigerator had shifted from dietary to housekeeping, and later confirmed that the thermometer was found buried under food containers and the temperature log was not current. Facility policy requires all prepared food brought in by family or visitors to be labeled with content and date, which was not followed in these instances.
Failure to Maintain Home-Like Environment Due to Persistent Odors
Penalty
Summary
Surveyors observed a strong and persistent urine odor throughout the facility, including upon entry, on the ramp to the upper level, and in hallways leading to resident rooms, all of which were carpeted. The odor was noted at multiple times over two consecutive days. When questioned, the Maintenance Supervisor was unsure of the carpet cleaning schedule and only after consulting with corporate staff stated that carpets are cleaned every six months by an outside company, but could not provide documentation or an invoice for the last cleaning. Additionally, the facility was unable to provide a policy for cleaning carpets or maintaining a home-like environment by the end of the survey. These findings demonstrate a failure to maintain a home-like environment free of offensive odors, as required, with the potential to affect all residents, staff, and visitors.
Deficient Water Management and PPE Use for Infection Control
Penalty
Summary
The facility failed to maintain an active and ongoing infection prevention and control program, specifically in relation to its Water Management Plan (WMP) and the use of Enhanced Barrier Precautions (EBP). Upon request, the Administrator provided a Legionella Surveillance policy and a Water Management Program document, but the latter was a generic template not tailored to the facility. The WMP lacked essential components such as a diagram or description of the building water system, a risk assessment, identification of areas where Legionella could proliferate, control points, monitoring evidence, and documentation of routine water management team meetings. Interviews with the Maintenance Supervisor and Infection Preventionist revealed a lack of involvement and understanding regarding the WMP, with both staff members being relatively new and unable to provide details about the program or its primary prevention strategies. Additionally, nursing staff did not consistently use appropriate PPE for EBP. During an observation, an LPN entered a resident's room with an EBP warning sign indicating the need for gown, gloves, and mask during high-contact activities, but failed to don any PPE while checking a feeding tube. The LPN was unaware of the EBP signage and unsure about PPE requirements for tube feeding placement checks. The Unit Manager confirmed that staff are expected to know the location of precaution signs and the corresponding PPE requirements, while the NHA/DON stated that PPE should be worn during high-contact activities to prevent infection control issues.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required eight hours of Registered Nurse (RN) coverage within a 24-hour period, as evidenced by a review of daily staff postings and timecard reports. Specifically, on May 27, there was not eight hours of RN coverage, and in June, RN coverage was missing for 13 out of 30 days. In July, RN coverage was missing for two out of the first ten days. The Director of Nursing (DON), who also served as the Nursing Home Administrator (NHA), acknowledged shared responsibility for ensuring RN coverage with a Unit Manager RN, and reported ongoing difficulties in maintaining stable staffing due to frequent call-ins. Requested documentation of staffing policies and RN coverage was not provided prior to the survey exit. All 37 residents in the facility were potentially affected by this deficiency.
Failure to Label Multi-Use Medications with Open Dates
Penalty
Summary
Surveyors observed that two multi-use, single resident ophthalmic medications (Restasis and Atropine Sulfate) stored in a medication cart were opened but not labeled with the date they were opened. During the review, an LPN confirmed that medications intended for single resident use should be labeled with both the resident's name and the date the medication was opened. The unit manager and the director of nursing both verified that the facility's expectation is for multi-use medications for single resident use to be dated upon opening. Additionally, when requested, the facility was unable to provide a policy regarding medication storage and labeling by the end of the survey. These findings indicate that the facility did not ensure all multi-use medications for single resident use were properly labeled with an open date, as required by professional standards and facility expectations.
Failure to Prevent Elopement Due to Inadequate Supervision and Faulty Door Alarm
Penalty
Summary
A resident with dementia and insomnia, identified as being at risk for elopement and having impaired cognition, was able to exit the facility unsupervised through a dining room door. The door alarm, which was intended to alert staff to unauthorized exits, was not functioning properly at the time of the incident. Staff became aware of the resident's absence only after a neighbor notified them that the resident was walking down the street. The resident was subsequently retrieved by staff and brought back to the facility. Review of facility records indicated that the door alarm had last been checked several days prior to the incident, and maintenance staff were unaware of the malfunction. The area where the resident exited was only partially fenced and the door did not have a lock. Staff interviews confirmed that the resident was known to be an elopement risk and that supervision was momentarily interrupted during a shift change, which coincided with the resident's exit. The facility's policy requires adequate supervision and functioning safety measures for residents at risk of wandering or elopement, which were not in place at the time of the event.
Failure to Maintain Homelike Environment and Backflow Protection
Penalty
Summary
The facility failed to maintain a homelike environment in the resident showers and ensure the ice machine on the first floor was backflow protected. Observations revealed that the ice machine drain line extended approximately 2 inches into the floor drain, which had a buildup of black mold. Additionally, the sink in the same room had lime build-up around the faucet aerator. Further observations of the facility's two shower rooms showed black mold and an unknown brown substance around the perimeter and on the walls of the showers. These findings were acknowledged by the Nursing Home Administrator, who indicated she would look into the concerns. The facility's policy on maintaining a safe and homelike environment was reviewed, highlighting the need for housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable environment.
Resident Transported in Undignified Manner
Penalty
Summary
The facility failed to transport a resident, identified as R901, from a doctor's appointment in a respectful and dignified manner. On the day of the incident, the resident was scheduled for a medical appointment for their foot. The transportation van was an hour and a half late for both the pickup and return trips. During the return trip, the van driver had two children without car seats in the vehicle, and the driver was observed cursing and hitting the children. The office manager at the doctor's office confronted the driver, who then cursed at the manager. Despite the inappropriate behavior, the resident was allowed to ride back to the facility with the children in the van. The resident reported being hit by the children with a book during the ride and that the children were cursing. The Nursing Home Administrator (NHA) was informed of the incident later that evening but did not follow up with the resident or their interested party regarding the situation. The facility's transportation policy outlines the need for safe and comfortable transportation, prohibiting personal use of facility vehicles, and addressing unsafe and abusive conduct. The policy also emphasizes preserving resident dignity, which was not upheld in this incident. The resident, who has a medical history including osteomyelitis, a pressure ulcer, and diabetes with a foot ulcer, was dependent on staff for activities of daily living and had intact cognition at the time of the incident.
Failure to Consistently Apply Wound Vac for Resident
Penalty
Summary
The facility failed to ensure that a wound vac was consistently applied for a resident who was reviewed for skin management. The resident, who had a history of osteomyelitis, pressure ulcer, and diabetes with a foot ulcer, was observed without a wound vac on their left foot after returning from a doctor's appointment. The wound vac was found in a bag with dried blood in the drainage tube and a large amount of blood in the reservoir. The resident's sister confirmed that the wound vac was removed at the doctor's office because the facility did not send the necessary supplies, and the Director of Nursing (DON) was supposed to reapply it the following morning. The Medication Administration Record (MAR) for the resident showed multiple instances where the wound vac was not documented as being applied, including specific dates where it was noted that the resident did not have a wound vac. The facility's policy on wound treatment management requires that wound treatments be provided in accordance with physician orders, but this was not adhered to in this case. The Nursing Home Administrator confirmed that the necessary supplies were not sent to the appointment, leading to the wound vac not being reapplied as required.
Inadequate Documentation of Showers for Dependent Residents
Penalty
Summary
The facility failed to adequately document showers for two dependent residents, R903 and R904, as part of maintaining complete medical records. Concerns were raised about the adequacy of showering and grooming for female residents. During an observation, R904 was found in bed, confused, and unable to communicate effectively. R904's medical record indicated a need for extensive to total assistance with activities of daily living due to conditions such as Dementia, Schizoaffective Disorder, and Diabetes. The review of R904's records showed only three shower sheets for a 60-day period, with two instances of refusal documented. R903 was also observed in bed and expressed uncertainty about their last shower. R903's medical record showed a need for limited to extensive assistance with activities of daily living due to a Traumatic Brain Injury, Dysphagia, and Chronic Kidney Disease. However, no shower documentation was provided for R903. The Nursing Home Administrator acknowledged the lack of documentation, which was not in compliance with the facility's policy on activities of daily living, which mandates necessary services for maintaining personal hygiene.
Inadequate Infection Control Program Documentation
Penalty
Summary
The facility failed to provide evidence of a comprehensive infection prevention and control program that included outcome and process surveillance, accurate data collection, documentation, and analysis. This deficiency potentially affected all 32 residents residing in the facility. During an interview, the Nursing Home Administrator (NHA) reported that the Director of Nursing (DON) was not present at the facility and that the infection control program documentation was with the DON, who was on vacation. Upon review, the Infection Control Program book lacked documentation of comprehensive surveillance and data analysis. The facility's policy stated that the designated Infection Preventionist is responsible for overseeing the program and consulting staff on infectious diseases, but the necessary documentation was not available at the facility.
QAPI Committee Meetings and Membership Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) committee met quarterly and was composed of the required committee members, potentially affecting all 33 residents residing in the facility. During a QAPI review, it was found that the sign-in sheets for the QAPI committee meetings were missing for several months, and when meetings did occur, they lacked the presence of key required members such as the Nursing Home Administrator (NHA) and the Director of Nursing (DON). Specifically, there were no sign-in sheets for meetings in July, August, September, and October 2023, and the meetings in May and June 2023 did not include the NHA or DON. Additionally, the meetings in November and December 2023 only had the Medical Director and a representative from Pharmacy present, and the February 2024 meeting included the Medical Director, Activities, Pharmacy, and the Minimum Data Set (MDS) nurse but still lacked other required members. The current NHA, who assumed the role on May 1, 2024, was unable to explain the missing meetings and required members. The facility's QAPI policy mandates that the QAA Committee be interdisciplinary and consist of the Director of Nursing Services, the Medical Director or designee, at least three other members of the facility's staff (including the Administrator, Owner, Board Member, or another individual in a leadership role), and the Infection Preventionist. The policy also requires the committee to meet at least quarterly. The failure to adhere to these requirements was identified during the review, highlighting a significant lapse in the facility's QAPI processes.
Failure to Implement Enhanced Barrier Precautions and Water Management Plan
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents identified with an indwelling urinary catheter device and skin impairment. Observations revealed that there was no signage for enhanced barrier precautions and no personal protective equipment other than gloves in or outside the rooms of the affected residents. One resident with an indwelling urinary catheter had no enhanced barrier precautions in place, and another resident with chronic wounds and cellulitis also lacked the necessary precautions. The care plans for these residents documented their conditions and the need for specific precautions, but these were not implemented as required by the facility's policy. Additionally, the facility's infection control surveillance was found to be lacking. The Director of Nursing, who also served as the Infection Control Preventionist, had been certified in June 2024 and had been working with the infection control program since January 2024. However, a review of the program documentation revealed no departmental surveillance documentation from May 2023 through December 2023. This indicates a significant gap in the facility's infection control practices and monitoring. The facility also failed to implement an active water management plan to reduce the risk of Legionella and other opportunistic pathogens in the plumbing system. The Administrator provided a company policy for Legionella surveillance but admitted that there was no water management program tailored to the specific building. The Maintenance Supervisor was unable to provide any information about a water management program, risk assessment, or a description of the building's water system, indicating a lack of preparedness and oversight in managing waterborne pathogens.
Failure to Conduct Regular Care Conferences
Penalty
Summary
The facility failed to ensure care conferences were conducted regularly for four residents, leading to a deficiency in the development and implementation of person-centered care plans. Resident R2, who has diagnoses including high blood pressure, stroke, and schizoaffective/bipolar disorder, had care conferences documented on 04/05/23 and 09/26/23, with the next one due on 01/14/24. However, no additional care conferences were completed as per the progress notes. Similarly, Resident R8, with diagnoses including schizoaffective disorder and dementia, had the last care conference on 02/28/23, with the next one due on 05/29/23, but no further care conferences were documented. Resident R20, with diagnoses including schizoaffective disorder and Parkinson's disease, had the last care conferences on 11/17/22 and 02/28/23, with no further documentation of care conferences completed. Resident R23, who has chronic kidney disease, diabetes, and vascular dementia, was also found to have missing care conferences. The last quarterly care conference for R23 was held on 10/30/23, with the next one due on 01/28/24. The facility's social worker admitted that care conferences had not been completed but were being scheduled for the current month. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) both confirmed that it is the facility's expectation to hold care conferences quarterly, but this was not adhered to. The facility's policy on care planning and resident participation, revised on 02/22/24, outlines the importance of informing residents and their representatives about their care plans and involving them in the decision-making process. The policy also emphasizes the need for regular care plan conferences and documentation. However, the facility failed to comply with its own policy, resulting in missed care conferences for the residents reviewed, thereby not ensuring their participation in the development and implementation of their person-centered care plans.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to follow up and document physician notification of pharmacy recommendations from medication regimen reviews for four residents. For Resident 2, the clinical record showed diagnoses including high blood pressure, stroke, and schizoaffective/bipolar disorder. The care plan indicated a risk for adverse consequences related to antipsychotic and antianxiety medication. Despite pharmacy concerns identified in medication regimen reviews dated August 2023 and February 2024, the actual reports were not received prior to the survey exit. Similarly, for Resident 8, who had diagnoses including schizoaffective disorder and dementia, the care plan documented a risk for adverse consequences related to antipsychotic medication. Pharmacy concerns were identified in reviews dated June 2023, August 2023, and February 2024, but the actual reports were not received, and it could not be determined if the concerns were addressed as the physician did not acknowledge the recommendations. For Resident 15, who had diagnoses including dementia and mood disorder, the pharmacy recommended monitoring Depakote levels every six months. However, lab results were not received by the end of the survey, and the Director of Nursing acknowledged the expectation that pharmacy reviews should be completed and followed up by the physician. Resident 23's case was not detailed in the report. The Nursing Home Administrator also confirmed the expectation for timely completion and follow-up of pharmacy reviews. A policy related to pharmacy reviews was requested but not received prior to the survey exit.
Failure to Maintain Effective Contact with Resident Representative
Penalty
Summary
The facility failed to obtain and maintain effective contact with the resident representative for a resident with multiple hospitalizations and significant medical conditions, including advanced dementia, chronic PEG tube for primary nutrition, and chronic obstructive pulmonary disease. Despite numerous attempts by various staff members, including social workers, nurses, and the activities director, the emergency contact listed for the resident was unreachable due to a busy signal or no answer. This lack of contact persisted over several months, during which the resident experienced multiple medical events, including hospital transfers for suspected aspiration pneumonia, COVID-19 with respiratory distress, and other emergencies. The deficiency was further compounded by the fact that the resident's legal guardian had been suspended, and no new legal representation was obtained. The social worker revealed that the guardianship process, which should have been initiated in 2021, was not pursued due to time constraints and the need for a filing fee from corporate. The Director of Nursing indicated that the expectation was for social work to take proper steps to obtain legal representation when an emergency contact could not be reached. However, this did not occur, leaving the resident without appropriate legal oversight and unable to make medical decisions independently.
Failure to Develop Elopement Baseline Care Plan
Penalty
Summary
The facility failed to develop an elopement baseline care plan for a resident who was admitted with diagnoses including Unspecified Dementia, Brief Psychotic Disorder, and Paranoid Personality Disorder. The resident was severely cognitively impaired and required supervision for ambulation. Despite being assessed as at risk of elopement, the baseline care plan did not include measurable goals and interventions to address the resident's priority risk factors and individual needs. This omission led to an incident where the resident left the facility and was found outside, although unharmed. Interviews with facility staff, including an LPN and the Director of Nursing, revealed that the door alarm went off when the resident exited the building. The Nursing Home Administrator and the Director of Nursing both acknowledged that baseline care plans should be completed within 48 hours of admission, as per the facility's policy. However, the review of the resident's baseline care plan showed that it lacked the necessary instructions to provide effective and person-centered care, contributing to the resident's elopement incident.
Failure to Implement Behavioral Management Care Plan
Penalty
Summary
The facility failed to implement care plan interventions for behavioral management of a resident on psychotropic medication. The resident, who has diagnoses including Schizophrenia, Malignant Neoplasm of Brain, and Diabetes Type 2, was observed in various states of restlessness and calmness. Despite being prescribed antipsychotic and antianxiety medications, there was no care plan addressing psychiatric behaviors or behavior related to these medications. The resident's Basic Interview for Mental Status (BIMS) score suggested moderate cognitive impairment, and their Minimum Data Set Assessment (MDS) indicated no mood or behavior concerns. During a Resident Council meeting, the resident became restless but calmed down when informed of a visit from their sister. The Director of Nursing (DON) confirmed that alternative measures to pharmacological intervention should be tried and documented before administering antipsychotic medication, as per the facility's Behavioral Health Services policy. However, the care plans lacked documentation of such alternative measures, leading to the deficiency.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to thoroughly complete a discharge summary for a resident who was transferred to another long-term nursing facility. The resident, who had diagnoses of Alzheimer's Disease, Heart Disease, and Hypertension, was discharged without a discharge summary or recapitulation of stay documented in the medical record. The resident's transfer was noted in progress notes, but the necessary discharge documentation was missing. Upon request for the discharge summary, the Nursing Home Administrator confirmed that the facility did not have a discharge summary for the resident and acknowledged the expectation that such a summary should be completed. The facility's Discharge Planning Process policy mandates that the evaluation of the resident's discharge needs and discharge plan be documented timely in the clinical record and that all relevant information be provided in a discharge summary to assist the resident in adjusting to the new living environment.
Failure to Follow Medical and Dental Recommendations
Penalty
Summary
The facility failed to follow a hospital recommendation, a physician's order, and follow up on a dental consultation for two residents. Resident R23, who has diagnoses including Chronic Kidney Disease, Diabetes, Chronic Obstructive Pulmonary Disease, and Vascular Dementia, was admitted to the facility after a hospital stay where a neurology consultation recommended an MRI and a follow-up with neurology. Despite a physician's order dated 3/15/24 for a follow-up with neurology in one week, the facility did not have an MRI for R23, as confirmed by the Nursing Home Administrator and the Director of Nursing. Resident R8, diagnosed with Schizoaffective Disorder Bipolar type, Anxiety, Dementia, and Depression, had a dental visit on 4/29/24 that recommended full mouth extractions before proceeding with denture impressions. The facility failed to document any contact with the responsible party or a consult to an oral surgeon for the extractions. A request for documentation of the referral on 6/13/24 revealed that no consultation or referral had been made for R8.
Failure to Supervise and Assess Fall Interventions
Penalty
Summary
The facility failed to supervise and assess the effectiveness of interventions for a resident (R23) who experienced multiple falls, resulting in hospital transfers. R23, who was admitted with diagnoses including Chronic Kidney Disease, Diabetes, Chronic Pulmonary Disease, and Vascular Dementia, was observed to be severely cognitively impaired and required extensive assistance for Activities of Daily Living. Despite these needs, R23 experienced 12 documented falls between January and May 2024, some of which resulted in injuries and hospital transfers. The falls occurred in various locations, including the resident's room, hallway, dining area, and bathroom, and were often unwitnessed or occurred when the resident attempted to self-transfer without assistance. A review of R23's care plan revealed numerous interventions aimed at preventing falls, such as providing toileting assistance, using anti-rollbacks on the wheelchair, and keeping the bed in the lowest position with brakes locked. However, these interventions were not revised following each fall, nor was there documentation addressing the effectiveness of the interventions already in place. The care plan had not been updated to reflect the resident's changing needs or to implement new strategies to prevent further falls. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator revealed that fall events were supposed to be addressed by the Interdisciplinary Team, and the Minimum Data Set nurse was responsible for updating care plans. However, the DON acknowledged that the effectiveness of interventions was an area needing improvement. The facility's Fall Prevention Program policy stated that each resident's risk factors and environmental hazards should be evaluated when developing the comprehensive plan of care, and interventions should be monitored for effectiveness and revised as needed. This was not done for R23, leading to repeated falls and hospital transfers.
Failure to Maintain Orders for Indwelling Catheter Care
Penalty
Summary
The facility failed to obtain and maintain orders for indwelling catheter care for a resident with multiple medical conditions, including chronic schizophrenia, depression/anxiety, dementia, obstructive uropathy with urinary retention, diabetes, and anemia. The resident, who had a BIMS score of 8 indicating moderate cognitive impairment, was observed on multiple occasions with an intact indwelling catheter. However, record reviews revealed that orders for catheter care and changes were discontinued on 6/7/2024, and no new orders were obtained thereafter. On 6/11/2024, the resident was observed in bed with the catheter bag on the bed, and on 6/12/2024, the resident was seen in the dining/activities room with the catheter bag concealed in the pocket of a reclining chair. Despite these observations, there were no active orders for catheter care or changes as of 6/7/2024. The Director of Nursing confirmed that the facility's expectation was to have orders for catheter care and changes documented in the medical record whenever a resident has an indwelling catheter, which was not adhered to in this case.
Failure to Ensure PRN Psychotropic Medications Had Adequate Indications and Stop Dates
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications had adequate indications for use and a stop date for one resident. The resident, who had diagnoses including Schizophrenia, Malignant Neoplasm of Brain, and Diabetes Type 2, was observed in bed and later in the activities/dining room. A record review revealed that the resident had two PRN antipsychotic medication orders for Haldol and Lorazepam, both lacking a reason for administration and a 14-day stop date. The Director of Nursing confirmed that it was the expectation for nursing staff to obtain clarification for incomplete orders. Interviews with two LPNs corroborated that orders for antipsychotic medications should include a reason and a stop date. The deficiency was identified through observation, interview, and record review, highlighting a lapse in the facility's medication management protocols.
Failure to Control Urine Odors and Ensure Adequate Ventilation
Penalty
Summary
The facility failed to ensure adequate ventilation and control of urine odors, as observed by surveyors on multiple occasions. Upon entry into the facility, a strong odor of urine and damp air was noted. Specific rooms, including room eleven and the entry between certain rooms, consistently had a strong urine odor. The resident bathroom also had a pungent urine odor. A resident reported that their room often smelled like urine, and staff acknowledged the chronic nature of the odor. The bathroom vent in room eleven was found to be ineffective, as it did not actively draw air when tested. The maintenance person confirmed that the vents were simply ducts venting to the roof, which did not provide adequate ventilation. The urine odor was observed to be stronger when the floor was mopped, and a housekeeping supervisor was seen cleaning up an unexpected urine spill in room eleven. Despite these efforts, the urine odor persisted in the room of a resident and the main entry area. The Nursing Home Administrator stated that she expects a clean and odor-free environment, but the facility's policy on maintaining a safe and homelike environment, which includes minimizing odors and ensuring adequate ventilation, was not effectively implemented. The policy review revealed that unresolved environmental concerns should be reported to the Administrator, and adequate outside ventilation should be provided through windows or mechanical means, which was not the case in this instance.
Facility Fails to Maintain Safe and Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to ensure food items and the kitchen were maintained in a safe and sanitary manner, potentially affecting all residents. During a tour of the kitchen, several issues were observed, including a large can of beans with rust on the bottom rim, rusted cans of fruit, and an open bag of pizza rolls in a chest freezer. The chest style vegetable freezer had significant frost build-up and a hard, non-pliable top seal, while the upright meat freezer had frost and ice buildup, rust, and spilled blood on a shelf. The chest style dairy freezer also had substantial frost build-up. The holding refrigerator contained warm food items, indicating it was not functioning properly, and had rust patches and ice buildup. The dietary manager acknowledged these issues but did not take immediate corrective action. Additional observations included a screen door propped open with milk crates, which the dietary manager explained was due to the kitchen getting warm. Half-pint milk containers in the beverage refrigerator were sticky and stuck together. The wall behind the steam table had peeling paint, and soil, food particles, and a straw wrapper were found at the base of the wall. Uncovered and uncooked rolls were left on a sheet pan on top of the steam table, and food debris was observed on top of standing plastic bins for cornmeal, flour, and sugar. The dietary manager later reported that the holding refrigerator was not working and would no longer be used. The Director of Nursing (DON) confirmed that the expectation was for meals to be served and the kitchen to be maintained in a safe and sanitary manner. A review of the facility's policies on food safety and cooler/freezer temperature monitoring revealed that the facility did not adhere to its own guidelines, which included maintaining proper food storage temperatures, monitoring equipment daily, and ensuring food safety practices were followed. The facility's failure to comply with these policies resulted in the observed deficiencies.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to ensure a clean and safe environment, which had the potential to affect all residents. During a facility tour, multiple rooms were found with various issues such as urine odor, clothes piled on the floor, holes in walls, chipped paint, dirty linens, and missing or broken fixtures. Specific observations included a baseboard heater cover that had fallen off, revealing bent and smashed fins, and rooms with significant cleanliness and maintenance issues such as soiled linens, dust buildup, and mold that could not be removed by the Maintenance Director. The Director of Nursing acknowledged these issues and stated that linens should be changed daily or every other day, and that rooms should be clean and comfortable for residents. Additionally, the facility failed to maintain tube feeding equipment in a clean and sanitary condition for one resident. The resident, who had diagnoses including Dementia and Gastrostomy Status, was observed with a significantly soiled tube feed/IV pole. The Director of Nursing confirmed that the equipment should never be as soiled as it was and should be cleaned immediately when it becomes soiled. The facility's policy on Environmental Services indicated that equipment should be cleaned and disinfected during deep cleaning procedures.
Loose Handrails in Upper Hallway
Penalty
Summary
The facility failed to ensure handrails were firmly mounted to the wall in the upper hallway, affecting five residents living in rooms along the hallway. During a tour of the facility, several handrails were observed to be loose and easily jiggled when pressure was applied. Specific locations included the inside corner at the right side of the food service elevator, the right of the kitchen/break room door, the left of the food service lift door, the right side of the office door, and between various rooms and bathrooms. These concerns were acknowledged by the maintenance supervisor and reviewed with the Director of Nursing (DON), who confirmed that the environment should be maintained to ensure resident safety. A policy related to the maintenance of the handrails was requested but not received prior to the survey exit.
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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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