Royalton Manor, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in St Joseph, Michigan.
- Location
- 288 Peace Blvd, St Joseph, Michigan 49085
- CMS Provider Number
- 235623
- Inspections on file
- 36
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Royalton Manor, Llc during CMS and state inspections, most recent first.
The facility failed to follow the published lunch menu and did not inform residents in advance of a menu change or notify the RD. The posted and internal menus listed BBQ chicken, macaroni and cheese, collards, corn bread, and sweet potato pie, but the meal actually served included green beans instead of collard greens. The Dietary Manager reported that collards were unavailable and she substituted green beans without RD approval, did not update the posted menu, and did not keep a log of substitutions or RD approvals, affecting all residents receiving meals from the kitchen.
Surveyors identified that desserts on resident meal trays were transported uncovered from the kitchen to a memory care unit, leaving sweet potato pie exposed to air during delivery. In addition, dietary management staff entered and moved through the kitchen without required hairnets, and one manager re-entered the kitchen, failed to perform hand hygiene, and retrieved beverages for a resident without washing hands. These practices did not comply with the facility’s nutritional services dress code or FDA Food Code requirements for covering food and using hair restraints around exposed food.
A resident with Alzheimer’s disease, type 2 DM, and anxiety, assessed as dependent for eating and ordered a regular mechanical soft diet with thin liquids, was left without a meal while seated with two other residents who had food. During the meal, another resident slid an open milk carton to him, which he drank, and he then took and ate a dessert and plate of food from the place setting of the resident next to him, despite that resident’s verbal protests. Multiple CNAs were present in the dining room and a social worker was at the nearby nurse’s station, but staff did not observe or intervene until after the resident had consumed other residents’ food, contrary to the DON’s stated expectation that residents at a table be served at the same time and in a timely manner.
A resident with dementia, severe cognitive impairment, and a known history of elopement and wandering continued to exhibit exit‑seeking behavior and repeatedly voiced intent to break and jump out of his window after a prior elopement through that window. Although maintenance installed a screw intended to limit window opening and similar screws on other windows, the maintenance director did not document follow‑up or physically test whether the windows could still be opened over the screws, relying only on visual checks. During the survey, a family member and the surveyor were able to unlock and fully open the resident’s window over the screw with little effort, and the window screen was damaged, while staff reported the resident and his daughter preferred the door closed and that the resident continued to talk about leaving and seek exits.
Two residents on regular diets reported that meals were unpalatable, with food described as cold, undercooked sausage, and french toast sticks that were “hard as a rock” and could not be cut with a fork, leading one resident to eat only one piece with her fingers and the other to be unable to eat the breakfast items at all. One resident also reported receiving two bowls of oatmeal she did not want, while another stated that lunch tasted terrible and did not match the posted menu item of collards, instead receiving green beans. Both residents repeatedly characterized the food as poor in taste and quality, and one sought fruit directly from the kitchen because she could not eat the served breakfast, despite the Dietary Manager stating that alternative “always ready” foods were available on request.
A resident with cognitive and physical impairments was kept in a geri-chair with a lap tray that acted as a physical restraint, despite regaining strength and showing signs of distress and agitation. Staff interviews and documentation confirmed the resident could not remove the tray independently and frequently expressed frustration, but the restraint was continued for convenience and fall prevention rather than medical necessity, contrary to facility policy.
The facility did not employ a Certified Dietary Manager to supervise the dietary department, relying instead on a staff member with only a ServSafe Food Handler certificate and no management training. There was also no full-time RD on site, with RD support provided remotely and in-person visits occurring infrequently due to staffing shortages.
Surveyors found that food items in the kitchen and storage areas were not consistently labeled or dated according to facility policy and FDA Food Code requirements. Items such as chicken salad, deviled eggs, milk, cheese, and sausage were observed without proper labeling, dating, or storage, creating the potential for foodborne illness among residents.
Surveyors found that several resident rooms, common areas, and equipment such as wheelchairs and dining chairs were not properly cleaned, with visible dust, debris, and stains present. Two residents had persistently dirty wheelchairs, and staff interviews revealed inconsistent cleaning routines and lack of documentation. Residents expressed dissatisfaction with the cleanliness of their environment, and observations confirmed widespread unclean conditions throughout the facility.
Two residents experienced inaccurate medication documentation, late or missed doses, and improper handling of controlled substances due to a nurse preparing and signing out medications before administration, failing to administer some medications as ordered, and using medication from another resident's supply. Medications were not always given within the required timeframe, and some were not administered at all during the observed pass.
Licensed nursing staff failed to maintain competency in medication administration, resulting in mismanagement of controlled substances and improper care for two residents. An RN was observed preparing and administering medications incorrectly, including using medications from another resident's supply and failing to document controlled substance administration as required. The facility lacked a process for ongoing competency evaluations for licensed nurses, contributing to these deficiencies.
Staff failed to maintain accurate documentation and inventory of controlled substances, resulting in multiple discrepancies between medication counts and records. A nurse administered a controlled medication late without proper documentation or physician order, and both an RN and an LPN made errors in recording and administering medications, including giving medication from one resident's supply to another. These actions led to unaccounted pills and conflicting records for several residents.
Staff failed to perform proper hand hygiene and did not follow Enhanced Barrier Precautions when entering and exiting a resident's room, including handling items without sanitizing hands and wearing artificial nails. Clean linens were carried against staff clothing and skin, and shared equipment such as mechanical lifts was found visibly soiled. The facility also lacked an effective water management program for Legionella prevention, with no documentation or clear protocols in place.
Two residents experienced significant weight loss due to the facility's failure to consistently monitor weights and document changes. One resident on enteral feeding had a notable decrease in weight without timely RD follow-up or physician notification, and another recently admitted resident was not weighed according to policy, with staff unaware of the weight loss. The facility did not update care plans or maintain required documentation for these cases.
Two residents were not offered or documented as having received timely influenza and pneumococcal vaccinations, with no records of vaccine history, education, or consent. The Infection Preventionist confirmed that immunizations should have been addressed at admission but were not completed or documented.
Two residents were not offered or properly documented for COVID-19 immunization upon admission. One resident had no record of vaccine education, administration, or consent, while another had no documentation of booster education or declination after admission, despite a history of prior vaccination. The Infection Preventionist confirmed that these steps were not completed or recorded as required.
A resident with Alzheimer's and dementia was accused of lying by the NHA after reporting an altercation between other residents. Despite being cognitively intact and having no history of fabrication, the resident was labeled as having a behavior problem. Multiple staff members, including CNAs and a Social Services staff member, confirmed the resident's credibility, but the NHA and Business Office Manager claimed otherwise without documentation support.
A facility failed to ensure timely physician orders and care for a resident's nephrostomy tubes, resulting in a five-day delay in monitoring and care. The resident, with a history of bladder cancer and severe sepsis, was admitted without necessary orders, and staff interviews confirmed the admitting nurse's responsibility to enter these orders. The lack of documentation on nephrostomy tube care during the initial days of admission highlighted the deficiency.
A resident with stage IV bladder cancer and nephrostomy tubes was admitted to a facility without proper orders for nephrostomy tube care. Despite the presence of the tubes being noted, there was no documentation of care or monitoring for several days. Staff reported that orders should have been in place upon admission, but there was a lack of communication and follow-up to ensure this. The Director of Nursing confirmed the admitting nurse's responsibility to enter such orders, leading to a deficiency in care.
A resident with a history of osteoporosis and Alzheimer's experienced a fall, resulting in a fracture. The facility failed to provide prompt medical care, as the initial assessment by an RN was inadequate, and the resident was moved without a thorough injury assessment. Despite severe pain and signs of a fracture, immediate hospital transport was delayed, contributing to the deficiency.
A resident with severe cognitive impairment was discharged from an LTC facility without proper authorization due to nonpayment. The facility failed to obtain the necessary approval from the Michigan Department of Licensing and Regulatory Affairs before proceeding with the discharge. Staff confusion about the approval process led to the resident being discharged on the proposed date without the required authorization.
A facility failed to provide a written notice of transfer for a resident with severe cognitive impairment, who was transferred to a hospital due to a change in condition. The facility's policy required notice before transfer, but it was found that transfer notices were not being given to residents or their representatives, leading to potential unawareness of the transfer and associated rights.
A facility failed to document a hypodermoclysis procedure for a resident with severe cognitive impairment, leading to potential inaccuracies in care assessment and communication. Despite staff training on the procedure, there was no record of it in the resident's medical records, causing confusion among staff about whether it was performed.
A resident with a history of heart and kidney issues experienced a 10-day delay in receiving antibiotic treatment for a UTI due to a communication breakdown and procedural issues. The NP waited for a paper copy of the sensitivity report before ordering treatment, despite having access to electronic results. The delay was compounded by the NP's lack of awareness that the urinalysis needed follow-up, as it was ordered by an on-call provider.
A facility failed to monitor a resident's antibiotic treatment for a UTI, lacking documentation of efficacy and adverse reactions. The resident, with multiple health conditions, was prescribed Nitrofurantoin Macrocrystal, but the care plan was delayed, and no Sepsis Screening Evaluation was completed. This oversight led to potential unrecognized side effects or ineffective treatment.
The facility failed to maintain accurate medical records for three residents, leading to incomplete care documentation. A resident's hypodermoclysis procedure was not documented, another resident's discharge process lacked comprehensive records, and a third resident's vital signs were not updated during a change in condition. Staff interviews confirmed these documentation lapses.
A resident with moderate cognitive impairment experienced a fall during a transfer due to a CNA's failure to follow the updated care plan requiring a two-person assist and the use of a gait belt. The CNA was unaware of the change and attempted the transfer alone, leading to the resident losing balance.
Unapproved Menu Substitution and Failure to Inform Residents of Meal Changes
Penalty
Summary
The facility failed to ensure that the published lunch menu was followed, that residents were informed of menu changes in advance, and that the Registered Dietitian (RD) was notified of these changes. The posted and facility menu for lunch on 3/18/2026 listed BBQ chicken, macaroni and cheese, collards, corn bread, and sweet potato pie. However, during a kitchen observation, the test lunch tray contained green beans instead of the planned collard greens. In an interview, the Dietary Manager stated that collard greens were not available, so she substituted green beans without obtaining prior approval from the RD, did not update the posted menu outside the dining room, and did not maintain a log of substitution changes or RD approvals. These actions and omissions resulted in the potential for all residents consuming food from the kitchen to be dissatisfied with their meal service and for meals to not be nutritionally adequate, as the menu was not served as planned, residents were not informed of the change, and the RD was not consulted regarding the substitution.
Uncovered Desserts and Lack of Hair Restraints in Dietary Services
Penalty
Summary
The deficiency involves failure to follow food safety and dress code standards in the dietary department, specifically related to uncovered food during transport and lack of required hair restraints in the kitchen. Surveyors observed a dietary aide transporting two carts of resident meal trays to the memory care unit, with multiple trays containing uncovered sweet potato pie desserts that were exposed to air. The facility’s own policies, as well as the 2022 FDA Food Code, require food to be stored and transported in covered containers or wrappings to protect it from cross-contamination. Surveyors also observed dietary management staff in the kitchen area without required hairnets and without performing hand hygiene upon entering the kitchen. One Dietary Manager walked across the kitchen without a hairnet to assist a staff member, then re-entered the kitchen, did not wash her hands, and retrieved orange juice and milk. In an interview, this manager acknowledged having a hairnet but stated she forgot to put it on and did not wash her hands, explaining that she was in and out of the kitchen frequently and did not touch food. On another occasion, a different Dietary Manager entered the kitchen, approached the steam table, accepted a plate of food from a dietary cook, and placed it on a tray while not wearing a hairnet. These actions were inconsistent with the facility’s Nutritional Services Department Dress Code, which requires hair restraints to prevent hair from contacting exposed food and related items.
Failure to Maintain Dignity and Supervision During Dining
Penalty
Summary
Failure to ensure dignity with dining occurred when a male resident with Alzheimer’s disease, type 2 diabetes, and anxiety, who was assessed as dependent for eating and required CNA assistance with meals, was left without appropriate meal service and supervision in the dining room. His care plan and orders specified a regular, mechanical soft (Level 3 Advanced) diet with thin liquids and enriched foods three times daily, and the Kardex indicated CNAs were to assist him with meals as needed. On one occasion, he was the last resident served and did not receive his meal tray until 14 minutes after he was observed sitting alone at a table. On a subsequent occasion, he was seated with two other male residents who had plates of food, while he had no food in front of him. During this later meal observation, an unknown resident pushed an open milk carton across the table to him, which he then drank. He subsequently reached into the place setting of the resident next to him, took that resident’s dessert bowl and spoon, and began eating it, then took the same resident’s plate and continued eating the remaining food. The resident whose food was taken verbally protested with single words such as “Hey!” and “Mine!”, while the first resident moved his arm to keep the plate out of reach. Throughout these events, multiple CNAs were present in the dining room and the social worker was seated at the nearby nurse’s station, but no staff observed or intervened until after the resident had consumed other residents’ food. The DON later stated his expectation was that each resident at a table be served at the same time and that meal trays be served timely.
Failure to Ensure Effective Post‑Elopement Window Safety Measures for an Exit‑Seeking Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and ensure the effectiveness of post‑elopement interventions for a resident assessed as an elopement risk. The resident was admitted with dementia with psychotic disturbance and anxiety, had a BIMS score of 4/15 indicating severe cognitive impairment, and was documented as ambulatory with a history of elopement attempts and wandering that placed him at significant risk of reaching dangerous areas. An FRI documented that the resident broke his room window and eloped from the memory care unit, after which one‑to‑one supervision was ordered until the window was amended. The resident’s elopement risk assessments and MDS continued to show a high elopement risk and wandering behaviors occurring on multiple days. Following the elopement, the care plan identified the resident as having a history of elopement out of the window and at risk for elopement related to dementia, with interventions including 1:1 care until the window was repaired. Progress notes over the subsequent months documented repeated statements by the resident about breaking and jumping out of the window, wanting to leave, and exit‑seeking behaviors such as wandering halls, going from door to door, pushing on exit doors, and packing belongings to leave. Staff notes indicated the resident was placed on 15‑minute checks at times due to wandering and exit seeking, and multiple entries described the resident expressing intent to break the window, jump out, or leave so that he might be harmed. Despite the resident’s ongoing exit‑seeking and window‑focused statements, the facility’s physical intervention on the window was not effectively monitored or verified. The maintenance director reported that after the elopement he installed screws on the resident’s window and other windows but did not document follow‑up, did not physically test the windows to see if they could be opened over the screws, and only visually confirmed the presence of screws. During surveyor observation, the resident’s family member and the surveyor were each able to unlock and open the resident’s window fully over the screw with little effort, and the window screen was observed to be busted at the bottom. Staff interviews confirmed that the resident and his daughter liked the door closed, and that the resident continued to talk about leaving and was exit seeking for a while after the elopement, while leadership acknowledged there was no documentation of window checks and that they believed the windows had been repaired.
Failure to Provide Palatable, Properly Prepared Meals
Penalty
Summary
The facility failed to ensure that food was palatable, appetizing, and properly prepared for two residents on regular diets with regular texture and thin liquid consistency orders. One resident with bipolar disorder, anxiety, and depression reported that the food was “yucky” and sometimes cold, and that staff did not reheat it when requested. On one morning, she anticipated receiving french toast sticks and stated she would eat them but expected they would probably be cold. Later that morning, her breakfast tray was observed at her bedside with the lid on the plate; she reported the food temperature was acceptable but stated the sausage was undercooked and the french toast sticks were “hard as a rock.” She demonstrated that she could not cut the french toast sticks with a fork, that only one of four was soft enough to bite, and that she had to eat the one she did consume with her fingers after covering it in syrup. Three french toast sticks and two sausage links remained on the plate, and the hardness of the french toast sticks was both seen and heard during the observation. Another resident with unspecified dementia, weakness, and a history of falls reported that breakfast “sucked,” describing the food as cold, the sausage as needing more cooking, and the french toast sticks as “rock hard,” which she stated she could not eat at all. Her tray contained two bowls of oatmeal and two cups of fruit; she reported she did not know why she received two bowls of oatmeal and that she would not eat even one, though she stated the fruit was acceptable. She later reported that lunch was “terrible,” did not taste good, and that she did not receive the collards listed on the menu but instead was served green beans, which she stated were not the same. On another morning, she reported she could not eat whatever was served for breakfast and was observed going to the kitchen to obtain fruit, stating that whatever she had been served “needed some help.” The posted menu for that day listed sausage links, cereal of choice, french toast sticks, and juice for breakfast, and chicken BBQ, macaroni & cheese, collards, cornbread, and sweet potato pie for lunch. The Dietary Manager stated that residents could request alternative choices from a list of “always ready” foods if they did not like something.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, anxiety disorder, major depressive disorder, and edema was subjected to the use of a geri-chair with a lap tray, which functioned as a physical restraint. The resident had previously been hospitalized and returned to the facility with decreased trunk control, leading to the initial use of the geri-chair for support. However, subsequent assessments and staff interviews indicated that the resident had regained strength and could sit unsupported, yet the use of the geri-chair and lap tray continued. Observations and interviews revealed that the lap tray and positioning of the geri-chair restricted the resident's mobility, preventing her from standing or moving independently. Multiple staff members, including CNAs and the DON, acknowledged that the resident was unable to remove the tray herself and frequently expressed distress, agitation, and frustration while restrained. Documentation in nursing progress notes and behavior logs showed repeated episodes of the resident banging on the tray, yelling, and attempting to get out of the chair, indicating ongoing emotional and physical discomfort. Despite the resident's improved physical condition and clear behavioral signs of distress, the facility continued to use the geri-chair and lap tray, primarily to reduce falls and for staff convenience, rather than for a current medical necessity. The facility's own restraint policy prohibits the use of physical restraints for convenience and requires reassessment with any significant change in condition. The required reassessment and communication with the hospice care coordinator regarding the resident's improved status and negative response to the restraint did not occur, resulting in the continued inappropriate use of a physical restraint.
Lack of Qualified Dietary Management and Inadequate RD Coverage
Penalty
Summary
The facility failed to employ a staff member with the appropriate credentials to supervise and manage the dietary department. During a kitchen tour, the Dietary Manager (DM) stated he was not a Certified Dietary Manager (CDM), was not enrolled in certification classes, and only held a ServSafe Food Handler certificate, which did not include management training. The DM also reported that the facility did not have a full-time Registered Dietitian (RD), and that RD support was limited to phone consultations and infrequent in-person visits, with the RD only visiting the facility a few times over two years. Corporate RD confirmed the DM's lack of CDM credentials and acknowledged that RD coverage was limited due to staffing shortages, with remote RDs assisting with documentation but being primarily assigned to other facilities.
Improper Labeling and Dating of Food Items in Kitchen
Penalty
Summary
Surveyors observed multiple instances of improper labeling and dating of food items in the facility's kitchen and food storage areas. During an initial tour, a small plastic container of chicken salad and a container of deviled eggs were found open with only the date of opening and no use by date. Additionally, a gallon of 2% milk was found open without any label or date. On a subsequent tour, cheddar cheese slices were found in a plastic bag with a use by date that had already passed, and sausage was stored in a metal pan that was only partially covered with aluminum foil. Review of the facility's Food Purchasing and Storage Policy confirmed that all food items in refrigerators are required to be properly dated, labeled, and stored in sealed containers or bags. The observations made by surveyors indicated that these procedures were not consistently followed, resulting in the potential for foodborne illness among residents consuming food from the kitchen. No specific residents were identified as being directly affected at the time of the survey.
Failure to Maintain Clean and Homelike Environment for Residents
Penalty
Summary
Surveyors observed multiple instances of uncleanliness and lack of maintenance in resident rooms and common areas. Dust, dirt, food, and paper debris were found along the wall and floor perimeters in several resident rooms, as well as in hallways and alcoves. Additional observations included a plastic drink lid with a red liquid and a dried red substance on the wall, as well as accumulations of personal items and debris under beds. These findings were corroborated by interviews with housekeeping staff, who described daily cleaning routines but did not provide evidence of consistent or thorough cleaning practices. Two residents were specifically noted to have unclean wheelchairs. One resident, who was cognitively intact, reported that her wheelchair was dirty and likely had not been cleaned. Observations over several days confirmed the presence of crumbs and dried food on and under the wheelchair cushion. Interviews with CNAs and LPNs revealed that while there was an expectation for night shift CNAs to clean wheelchairs, there was no specific schedule or documentation to ensure this was done. The DON acknowledged that cleaning wheelchairs was a challenge and that the process was supposed to be coordinated with resident shower days, but this was not consistently implemented. In the memory care unit, a resident reported that dining chairs needed more frequent cleaning and pointed out dust and debris on the chair frame. Observations confirmed that most dining chairs and table bases were soiled with dried liquids, crumbs, and dust. Multiple brown and yellow stains were noted on the carpets in entryways and common areas, and a heavily soiled emergency exit door was also observed. These conditions contributed to decreased satisfaction with the living environment among residents.
Failure to Follow Professional Standards During Medication Administration
Penalty
Summary
The facility failed to follow professional standards of practice during medication administration for two residents, resulting in inaccurate documentation, late or missed medications, and the potential for worsening medical conditions. For one resident with a history of blood infection requiring IV antibiotics, the nurse was unsure if the IV medication had been administered as scheduled. During observation, the nurse prepared both IV and oral medications, but several medications were signed out as administered before they were actually given. Some medications were not observed being administered at all, and others were documented as not given without explanation. The IV medication was left attached to the resident for longer than ordered, and the nurse was unable to explain the proper administration process. Additionally, the nurse reported administering a controlled pain medication after the scheduled time but could not verify or properly document this, and it was later discovered that the medication may have been taken from another resident's supply. For the second resident, the nurse was observed retrieving unlabeled medications from the medication cart that had been pulled earlier and stored together, rather than preparing them immediately prior to administration as required by policy. The nurse administered a group of oral medications and insulin more than an hour after the scheduled time, and some ordered medications were not observed being given at all. The nurse also made a verbal error regarding the injection site for insulin. Review of physician orders and the medication administration record confirmed that several medications were not administered within the required timeframe, and some were not administered at all during the observed medication pass. Facility policy requires medications to be prepared immediately prior to administration, prohibits administering medications from one resident's supply to another, and mandates that medications be administered within 60 minutes of the scheduled time. Documentation is to occur immediately after administration, not before. The observed practices deviated from these standards, resulting in inaccurate records, late or missed doses, and improper handling of controlled substances.
Failure to Ensure Nursing Staff Competency Leads to Medication Mismanagement
Penalty
Summary
The facility failed to ensure that all licensed nursing staff maintained the necessary competencies and skills to provide appropriate care to residents, resulting in mismanagement of controlled substances and improper medication administration. During medication administration, a registered nurse (RN) was observed handling medications that were not labeled with resident names and preparing them in advance, contrary to facility policy. The RN also demonstrated a lack of knowledge regarding insulin injection sites and the operation of IV medication administration, as evidenced by her inability to explain the process or duration for a resident's IV antibiotic therapy. Further review revealed that the RN administered a controlled substance, Tramadol, to a resident without proper documentation or verification of orders, and took the medication from another resident's supply. The RN failed to document the administration of controlled substances on the required inventory sheets, instead recording them on a piece of paper with the intention to update records later. Discrepancies were found between the number of doses signed out and those actually administered, and the RN could not provide clear explanations for these actions during interviews. The investigation also uncovered that the facility did not have a process in place for ongoing competency evaluations of licensed nursing staff after orientation. The staff development educator confirmed that only certified nursing assistants received competency evaluations, and there was no system to ensure that licensed nurses remained competent in their roles. This lack of oversight contributed to the observed deficiencies in medication management and resident care.
Failure to Accurately Document and Account for Controlled Substances
Penalty
Summary
The facility failed to maintain accurate and clear documentation of controlled substance counts and administration, impacting nine residents across two medication carts. Registered Nurse (RN) JJ did not administer a resident's prescribed Tramadol as scheduled because it was not available in the medication cart, and subsequently administered the medication later without proper documentation or a physician's order for the late dose. RN JJ also failed to document the administration of controlled substances on the appropriate inventory sheets, instead recording them on a separate piece of paper with the intention to update the records later. This led to discrepancies between the actual medication counts and the documented inventory for multiple residents. Observations and interviews revealed that controlled substance counts for several residents did not match the inventory sheets, with pills unaccounted for in multiple cases. For example, one resident's Tramadol card had fewer pills than indicated on the inventory sheet, and similar discrepancies were found for other controlled medications such as Clonazepam, Oxycodone, Morphine, Hydrocodone/Acetaminophen, and Hydromorphone. Additionally, an LPN reported signing out a medication that was later refused by a resident, but the MAR indicated the medication was administered and effective, showing conflicting documentation. Another instance involved a nurse possibly administering medication to the wrong resident with a similar order. Further review determined that RN JJ had taken Tramadol from one resident's supply and administered it to another without proper documentation, and attempted to return medication to the original card from the backup supply. The Director of Nursing confirmed multiple errors in documentation and administration, including actual medication errors and failure to follow professional standards and facility policy. The facility's records and staff interviews consistently showed a lack of adherence to required procedures for controlled substance management and documentation.
Infection Control Failures in Hand Hygiene, Linen Handling, Equipment Cleaning, and Water Management
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several key areas. Staff did not perform adequate hand hygiene when entering and exiting a resident's room under Enhanced Barrier Precautions (EBP), nor did they demonstrate understanding of the EBP signage or requirements. Both an Activities Aide and a Certified Nursing Assistant entered the room without performing hand hygiene, handled items within the room, and wore artificial nails that extended beyond the fingertips, contrary to infection control recommendations. The resident involved was cognitively intact and had a stage 2 pressure wound, increasing the importance of proper infection control. Additionally, clean linens were observed being transported improperly, with a CNA carrying towels and washcloths under her arm, allowing them to come into contact with her clothing and exposed skin. This practice was acknowledged by the Infection Preventionist as inappropriate due to infection control concerns. Shared resident equipment, such as mechanical lifts, was found to be visibly soiled with dirt, dust, and dried substances, and staff interviews confirmed that such equipment should be cleaned after each use to prevent cross-contamination. The facility also failed to maintain an effective water management program to prevent Legionella. The Maintenance Director was unaware of the facility's protocols for Legionella prevention, including water sampling and documentation of flushing procedures for off-line rooms. There were no logs or evidence of compliance with the facility's policy, which requires regular cleaning, disinfection, and documentation to minimize the risk of Legionella and other water-borne pathogens.
Failure to Monitor and Document Weight Loss in Residents
Penalty
Summary
The facility failed to ensure timely and consistent weight monitoring and complete and accurate documentation for two residents, resulting in undetected weight changes and the potential for nutritional status decline. One resident, who was admitted with diagnoses including weakness and dysphagia and was receiving enteral feeding via PEG tube, experienced a significant weight loss of 6.48% over a short period. Despite this, there was no documentation from the Registered Dietitian (RD) or Dietary Manager (DM) regarding the weight loss after it was initially identified, nor was there evidence that the physician was notified. The resident's care plan was not updated to reflect the weight loss, and there was no follow-up assessment or intervention documented by the RD after the admission nutrition evaluation. Another resident, recently admitted following two surgeries, also experienced significant weight loss. The weight records showed inconsistent monitoring, with a three-week lapse between weighings and a substantial drop in weight. Staff interviews revealed confusion about who was responsible for monitoring and addressing weight loss, and the Dietary Manager admitted to not being aware of the resident's weight loss or having spoken to the resident about it. The facility's policy required weekly weights for new admissions and for residents with significant weight changes, but this was not followed for this resident. The facility's own Weight Management Policy stipulated that residents at risk or with significant weight changes should be weighed weekly, and that the RD should assess and make recommendations to prevent or treat unintended weight loss. However, these procedures were not followed for either resident, as evidenced by the lack of timely weight monitoring, absence of documentation, and failure to update care plans or notify the physician as required.
Failure to Offer and Document Timely Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure that eligible residents were offered influenza and pneumococcal vaccinations in a timely manner, as required. For two residents reviewed, there was no documentation of influenza or pneumococcal vaccination history, education, or consent being offered. Specifically, one resident had no record of either vaccine or related education and consent upon admission, and the Infection Preventionist confirmed that the immunization process had not been completed for this resident. Another resident had historical documentation of receiving two pneumococcal vaccines but lacked any record of influenza vaccination, education, or consent. The Infection Preventionist acknowledged that immunizations should have been addressed at admission for both residents, but this was not done or documented.
Failure to Offer and Document COVID-19 Immunization for Residents
Penalty
Summary
The facility failed to ensure that COVID-19 immunizations were offered and properly documented for two of five residents reviewed. For one resident, there was no record of COVID-19 vaccine administration, education, or consent on file, and the Infection Preventionist confirmed that immunizations had not been discussed upon admission. For another resident, although there was documentation of four prior COVID-19 vaccine doses before admission, there was no documentation of further booster education, declinations, or consents after admission. The Infection Preventionist acknowledged that these discussions and documentation should have occurred at the time of admission, but there was no record of them.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to protect a resident's right to dignity and respect, as evidenced by an incident involving a cognitively intact resident with Alzheimer's disease, dementia, depression, and anxiety. The resident reported witnessing an altercation between two other residents and informed the Nursing Home Administrator (NHA). The NHA allegedly responded by calling the resident a liar, which led to the resident feeling upset and crying. This interaction was witnessed by a Licensed Practical Nurse (LPN), who confirmed the resident's account of being called a liar by the NHA. The incident was also discussed in a morning meeting attended by various department heads, where it was noted that the resident had reported the altercation to another resident's family member. Despite the resident's cognitive intactness and lack of history of fabricating stories, a care plan was created labeling the resident as having a behavior problem related to making false accusations. Interviews with multiple Certified Nursing Assistants (CNAs) and a Social Services staff member indicated that the resident was not known to fabricate stories. The NHA, however, maintained that the resident had a history of making things up, although no documentation in the resident's chart supported this claim. The Business Office Manager also described the resident as someone who gossips and lies, but this was not corroborated by other staff or documentation.
Failure to Ensure Timely Nephrostomy Tube Care
Penalty
Summary
The facility failed to adhere to professional standards by not ensuring that physician orders were in place for the monitoring and care of nephrostomy tubes for a resident. The resident, who had a history of malignant neoplasm of the bladder, severe sepsis, and infection due to nephrostomy catheters, was admitted to the facility without the necessary orders for nephrostomy tube care. Despite the presence of discharge papers that should have served as admission orders, the admitting nurse did not enter the required orders, nor did they contact the on-call provider to obtain them. This oversight resulted in a delay of five days before the orders for monitoring and care of the nephrostomy tubes were put in place. Interviews with facility staff, including LPNs, an RN, the wound nurse, and the DON, confirmed that the responsibility for entering admission orders, including those for special devices like nephrostomy tubes, lay with the admitting nurse. The staff acknowledged that the resident should not have gone without orders over the weekend following admission. The lack of documentation regarding the monitoring and care of the nephrostomy tubes during the initial days of the resident's stay further highlighted the deficiency in adhering to professional standards of care.
Failure to Provide Nephrostomy Tube Care
Penalty
Summary
The facility failed to provide proper care for a resident with nephrostomy catheters, which are tubes placed through the skin into the kidneys to drain urine. The resident, who had a history of stage IV bladder cancer and severe sepsis, was admitted to the facility with bilateral nephrostomy tubes. Upon admission, the resident's nephrostomy sites were covered with appropriate dressings, but there was no documentation of care or monitoring of the nephrostomy tubes for several days following admission. The facility's staff, including LPNs and RNs, reported that orders for nephrostomy tube care should have been in place upon the resident's admission. However, there was a lack of communication and follow-up to ensure these orders were obtained and documented. The Wound Nurse confirmed that no orders were entered for the care or monitoring of the nephrostomy tubes until five days after the resident's admission, despite the presence of the tubes being noted in the admission paperwork. The Director of Nursing acknowledged that the admitting nurse was responsible for entering orders for special devices like nephrostomy tubes. The facility's failure to have orders in place for the care and monitoring of the resident's nephrostomy tubes resulted in a lack of documented dressing changes and monitoring for several days, which could potentially lead to complications such as infection or catheter dislodgement.
Failure to Provide Prompt Medical Care After Resident Fall
Penalty
Summary
The facility failed to provide prompt medical care after a fall for a resident, resulting in significant pain and a delay in emergent care. The resident, who had a history of osteoporosis, Alzheimer's disease, and previous falls, experienced a fall that was witnessed by staff. Despite the fall being observed, the initial assessment by the responding RN was inadequate, as the resident was moved without a thorough assessment for injuries. The RN did not immediately recognize the signs of a potential fracture, such as the outward rotation and shortening of the resident's right leg, and did not pursue immediate transport to the hospital. The resident's pain was later assessed as severe, with a pain level of 8 out of 10, and an x-ray confirmed an acute fracture. Interviews with staff revealed that the resident was in significant distress, unable to bear weight on the affected leg, and exhibited signs of pain and injury. The LPN who later assessed the resident noted the need for immediate hospital evaluation, which was not initially pursued by the RN. The delay in recognizing the severity of the injury and the failure to transport the resident promptly to the hospital contributed to the deficiency. Interviews with the facility's staff, including the DON and other nursing staff, highlighted the expectation that a full assessment should be conducted immediately after a fall, prior to moving the resident. The staff acknowledged that the resident should have been sent to the emergency room immediately upon identifying the signs of a serious injury. The family member and DPOA for the resident also expressed that the resident should have been transported to the hospital for evaluation immediately after the fall, indicating a lapse in following the appropriate protocol for post-fall care.
Improper Facility-Initiated Discharge Due to Nonpayment
Penalty
Summary
The facility failed to follow proper procedures for a facility-initiated discharge of a resident, resulting in an untimely and unapproved discharge. The resident, who had severe cognitive impairment due to Alzheimer's disease, dementia with mood disturbances, and generalized anxiety disorder, was given a notice of involuntary transfer or discharge due to nonpayment. The notice was dated over a month before the proposed discharge date, and the facility was required to have a discharge plan approved by the Michigan Department of Licensing and Regulatory Affairs before proceeding. Despite this requirement, the facility discharged the resident on the proposed date without having received the necessary approval. Interviews with facility staff revealed confusion about the approval process, with the social worker and accounts receivable coordinator both mistakenly believing they had received approval. The approval letter was only provided to the surveyor two weeks after the discharge, indicating that the discharge occurred without the proper authorization, as confirmed by electronic communications from the regulatory body.
Failure to Provide Transfer Notice
Penalty
Summary
The facility failed to provide written notice of transfer for a resident who was reviewed for hospital transfers. This deficiency was identified during an interview and record review, where it was found that the resident and/or the resident's representative were not informed of the transfer, the reasons for the transfer, or the resident's rights. The resident in question had diagnoses including repeated falls, altered mental status, and adult failure to thrive, and was assessed to be severely cognitively impaired with a BIMS score of 3/15. The facility's policy required that notice be made as soon as practicable before transfer or discharge, especially in cases of emergency transfer to an acute care facility. However, it was revealed that the transfer notices were kept in a folder at each nurse's station and were not being given to residents or their representatives prior to any transfer or discharge. This oversight resulted in the potential for the resident and/or their representative to be unaware of the transfer and the associated rights.
Failure to Document Hypodermoclysis Procedure
Penalty
Summary
The facility failed to maintain professional nursing standards of documentation for a resident, resulting in potential inaccuracies in assessment and communication of care needs. The resident had diagnoses including repeated falls, altered mental status, and adult failure to thrive, and was severely cognitively impaired. There was a discrepancy regarding whether the resident received hypodermoclysis, a procedure requiring a physician's order and proper documentation. Interviews with various staff members, including the Director of Nursing, Registered Nurse, Nurse Practitioner, and Licensed Practical Nurses, revealed conflicting accounts about whether the procedure was performed on the resident. Despite education and training provided on hypodermoclysis, including the importance of documentation, there was no record of the procedure in the resident's medical records, medication administration record, or progress notes. The lack of documentation led to uncertainty among staff about whether the procedure was actually performed, highlighting a failure in maintaining accurate and complete medical records for the resident's care.
Delayed Treatment for UTI Due to Communication Breakdown
Penalty
Summary
The facility failed to provide timely treatment for a urinary tract infection (UTI) for a resident, resulting in a delay of 10 days before antibiotic treatment was initiated. The resident, who had a history of paroxysmal atrial fibrillation, heart failure, and chronic kidney disease stage 3, had a positive urine culture result on 6/29/24. Despite the positive result, the antibiotic treatment was not ordered until 7/10/24. The delay was due to a communication breakdown and procedural issues within the facility. The nurse practitioner (NP) acknowledged the positive result on 6/29/24 but waited for a paper copy of the sensitivity report before ordering treatment, as per facility instructions. However, the infection preventionist noted that the NP had access to the results in the electronic medical record and did not need to wait for the paper copy. Additionally, the regional clinical coordinator discovered that the NP was not aware of the need to follow up on the urinalysis because it was ordered by an on-call provider, not by the NP herself. This miscommunication and procedural delay led to the resident not receiving timely treatment for the UTI.
Failure to Monitor Antibiotic Efficacy and Adverse Reactions
Penalty
Summary
The facility failed to consistently and timely monitor the antibiotic medication efficacy and adverse reactions for a resident diagnosed with Paroxysmal Atrial Fibrillation, Heart Failure, and Chronic Kidney Disease Stage 3. The resident had a positive urine culture indicating a UTI and was prescribed Nitrofurantoin Macrocrystal. Despite the prescription, there was a lack of documentation regarding the monitoring of the antibiotic's adverse reactions or efficacy during the treatment period. The care plan addressing the UTI and antibiotic treatment was developed and implemented five days after the treatment began, with no prior care plan focus on the UTI and antibiotic treatment. An interview with the Infection Preventionist revealed that residents on antibiotics should be monitored daily for improvement and side effects, with documentation in the form of a Sepsis Screening Evaluation. However, a review of the resident's electronic medical record showed no such evaluation had been completed since April 2022. This lack of monitoring and documentation resulted in the potential for unrecognized side effects or ineffective treatment for the resident.
Deficiencies in Medical Record Documentation for Three Residents
Penalty
Summary
The facility failed to maintain clear, concise, and accurate medical records for three residents, leading to incomplete records of care needs and the potential for diminished medical outcomes. For Resident #101, there was a lack of documentation regarding the initiation and administration of hypodermoclysis, despite verbal orders and educational training being conducted. The Medication Administration Record and Progress Notes did not reflect the procedure, which was confirmed by interviews with staff who witnessed the procedure. Resident #106's discharge process was inadequately documented. Although the social worker communicated with the resident's guardian about discharge plans, the medical record lacked comprehensive documentation of the discharge process. Interviews with staff revealed discrepancies in the discharge documentation, with some staff unaware of the resident's transfer to the hospital, and others failing to document the discharge in the resident's records. For Resident #104, there was a significant gap in the documentation of vital signs between specific dates, despite the resident experiencing a change in condition. The Change in Condition form used outdated vital signs, and staff interviews indicated that the form should have been updated with current measurements. The facility's policy emphasized the importance of obtaining vital signs during a change in status, which was not adhered to in this case.
Unsafe Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, resulting in a fall and potential injury. The resident, who had a moderate cognitive impairment and was diagnosed with pulmonary embolism and anxiety, was being assisted by a CNA during a transfer from bed to wheelchair. The CNA, who was unaware of the recent change in the resident's care plan from a one-person to a two-person assist, attempted the transfer alone without using a gait belt, leading to the resident losing balance and being eased to the floor. Interviews and record reviews revealed that the CNA had been educated on proper transfer techniques, including the use of gait belts, but did not adhere to the updated care plan. The CNA was unclear about the resident's transfer requirements, and the facility's policy mandates the use of gait belts for safety during transfers. The incident highlighted a lapse in communication and adherence to the care plan, resulting in an unsafe transfer situation.
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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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