Sanilac Medical Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Sandusky, Michigan.
- Location
- 137 North Elk Street, Sandusky, Michigan 48471
- CMS Provider Number
- 235157
- Inspections on file
- 20
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Sanilac Medical Care Facility during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, severe cognitive impairment, muscle weakness, and a prior right tibia fracture required dependent assistance for transfers and had a care plan specifying use of a Hoyer lift with a red-trim sling and an assist of one. On one morning, a CNA instead performed a two-person manual transfer of the resident into a personal wheelchair, deviating from the written transfer plan despite having been trained on it. Later that morning, the resident complained of right lower extremity pain with deformity, and imaging showed acute displaced fractures of the distal tibia. Subsequent observations and staff interviews confirmed that mechanical lifts and correctly colored slings were readily available and that staff were expected to follow the transfer instructions posted in the resident’s closet, indicating the deficiency arose from failure to follow the individualized plan of care during the transfer.
A resident with significant cognitive and psychiatric needs was subjected to verbal abuse by a CNA, who called the resident 'crazy' and made other derogatory remarks in the presence of the resident and others. The incident was witnessed by another CNA, and the resident expressed distress and refused care as a result. The resident's care plan required a non-confrontational environment, which was not maintained during the incident.
A resident developed an unstageable pressure ulcer due to the facility's failure to ensure comprehensive documentation and evaluation. The resident, with multiple diagnoses, was admitted with a stage 4 pressure ulcer. Upon readmission, the coccyx/sacrum area was initially documented as MASD, but inconsistent monitoring led to the development of a large necrotic unstageable ulcer. The facility's policies on skin inspection and wound care were not adequately followed, contributing to the deficiency.
Two residents in a LTC facility sustained injuries due to staff failing to follow prescribed transfer protocols. One resident, with a history of stroke and weakness, suffered foot fractures during a transfer when only one staff member assisted instead of the required two. Another resident, with a history of femur fracture, was lowered to the floor by a single CNA, contrary to the care plan requiring two-person assistance, resulting in pain and a decline in transfer status.
A facility failed to administer a nebulizer treatment according to standards, as a nurse did not assess or monitor a resident during treatment. Additionally, two residents did not receive medications as prescribed, with one not receiving an inhaler and medications given late. Another resident was prescribed multiple psychotropic medications without proper consent or documentation of non-pharmacological interventions.
The facility failed to implement a comprehensive infection control program, lacking hand hygiene supplies and proper practices. Staff were observed not performing hand hygiene, and infection control audits were inadequately documented. Residents with ongoing infections were not properly monitored, and catheter care was substandard, increasing infection risk.
The facility failed to obtain informed consent before initiating antipsychotic medication for two residents with severe cognitive impairment. One resident was started on Seroquel and Clonazepam without proper documentation or consent, while another was given Ativan without prior notification to the responsible party. The facility's policy requires education on risks and benefits and obtaining consent, which was not followed.
A facility failed to respect a resident's choice in guardianship, leading to distress for the resident. The resident, who requires assistance with all care, was upset because the facility initiated legal action to remove her sister as her guardian due to unpaid expenses after a Medicaid eligibility issue. The facility did not effectively communicate with the resident or her guardian, leading to confusion and distress. The facility's actions were not aligned with the resident's rights to self-determination and choice.
The facility failed to update care plans for residents with severe cognitive impairments who experienced multiple falls and infections. A resident with a history of traumatic brain injury and paraplegia had repeated falls and hospitalizations for UTIs, but care plans lacked new interventions. Another resident with Alzheimer's disease had falls without proper care plan updates or implementation of interventions. A third resident with dementia had falls without appropriate care plan revisions, and some interventions were inappropriate. The facility's policy for incident investigation and intervention implementation was not consistently followed.
A resident with multiple medical conditions, including a Stage 4 sacral pressure ulcer and an amputation, was found with long, soiled fingernails and cracked toenails due to the facility's failure to provide routine nail care. The resident, who required substantial assistance with hygiene, reported that staff had not trimmed her nails in a while, and her care plan did not specifically address nail care.
A facility failed to administer oxygen per physician's order and did not store nebulizer equipment sanitarily for a resident with respiratory needs. The resident's oxygen concentrator was set to 5 liters per minute instead of the ordered 6 liters, and the nebulizer mask was improperly stored. The resident had diagnoses including COPD, Stroke, and CHF, requiring assistance with all ADLs.
A facility failed to coordinate dialysis care for a resident with multiple health issues, including chronic kidney disease and dialysis dependence. The Hemodialysis Communication Forms often lacked information on the dialysis access site and post-dialysis instructions. The facility's records did not mention the dialysis access site, and nurses failed to document the required post-dialysis site assessment. The Director of Nursing acknowledged these documentation and assessment deficiencies.
A facility experienced a 26.19% medication error rate due to omitted and delayed medication administration for two residents. A nurse failed to administer Protonix and Symbicort inhaler to a resident, while another resident received several medications late. The Clinical Supervisor cited resident preferences and workload as contributing factors.
A nurse improperly stored medications, including a narcotic, during administration. Medications were placed in a cup and left in the medication cart drawer, including an inhaler and Lyrica, a controlled substance. The nurse was unaware of the facility's policy on medication storage, and the DON confirmed that narcotics should be stored under two locks.
The facility failed to implement a comprehensive antibiotic stewardship program, leading to inappropriate antibiotic use for two residents. One resident with multiple health issues received various antibiotics without effective monitoring, resulting in a multi-drug resistant organism. Another resident continued antibiotic treatment despite a negative culture result. The facility did not adhere to its policies on infection control and antimicrobial stewardship, lacking oversight and communication with providers.
A facility failed to assess and monitor a resident's hydration status, resulting in undocumented IV fluid administration and no family notification. The resident, with a history of Diabetes Type 2 and Chronic Kidney Disease, had high sodium levels indicating dehydration. Despite orders for a saline bolus, there was no record of the amount administered before the resident removed the IV. The DON confirmed the lack of documentation and family notification, leading to the resident's hospital admission for Hypernatremia.
A resident with early onset Alzheimer's was admitted to a facility without psychotropic medications but was later prescribed multiple such drugs without baseline testing or monitoring. The resident's health declined, leading to decreased liver and kidney function, and he was hospitalized multiple times before passing away. The facility failed to provide adequate education and consent about the medications' risks, contributing to the resident's decline.
Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Tibia Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident safety by not following care-planned interventions during a transfer to a wheelchair. A resident with Alzheimer’s disease, muscle wasting and atrophy, muscle weakness, need for assistance with personal care, and a right tibia fracture was admitted and later readmitted to the facility. The resident’s Minimum Data Set showed severely impaired cognition with a Brief Interview of Mental Status score of 0/15, and dependence on staff for transfers, bathing, dressing, and personal hygiene. The resident’s individualized plan of care required use of a mechanical lift (Hoyer lift) with a red-trim sling for transfers, with an assist of one person at the time of the incident. On the morning in question, a CNA reported assisting the resident into her personal wheelchair prior to 6:00 AM using a two-person manual transfer instead of the required mechanical lift with the red-trim sling. This action deviated from the resident’s individualized plan of care, which clearly specified use of the Hoyer lift and sling, and the CNA had been appropriately trained on this requirement. The CNA could not recall who assisted with the transfer and reported that the resident did not complain of pain and that no accident or injury occurred at that time. The evening before, the resident had been transferred back to bed by a CNA and a nurse, and the sling used for that transfer had been soiled and sent to the laundry. Later, at approximately 8:30 AM, staff notified the DON that the resident was complaining of pain in the right lower extremity, with deformity noted, and no fall, accident, or injury had been witnessed or reported. Diagnostic imaging at the hospital revealed an acute comminuted mildly displaced fracture of the distal tibial metadiaphysis and an acute mildly displaced fracture of the distal tibial diaphysis. Subsequent observations during the survey showed the resident sitting in a wheelchair with the right leg elevated in a cast and a red-trim mechanical lift sling positioned underneath her, with a mechanical lift available in the hallway. Interviews with laundry and CNA staff confirmed that there were sufficient mechanical lifts and appropriately colored slings available, and that staff were aware that transfer requirements were listed in the resident’s closet care plan. The facility’s failure occurred when the CNA did not follow the resident’s established transfer plan of care and used a manual transfer instead of the required mechanical lift and sling.
Failure to Prevent Verbal Abuse of Resident by CNA
Penalty
Summary
A deficiency occurred when a resident, who had a history of stroke, dysphagia, adjustment disorder with anxiety, and major depressive disorder, and who required assistance with all activities of daily living and was deemed incompetent to make medical decisions, was subjected to verbal abuse by a certified nursing assistant (CNA). The resident reported to surveyors that a staff member had laughed at their grandmother and expressed feelings that the staff member was antagonistic towards them. During care, the resident refused assistance from the CNA in question, and another CNA witnessed the accused CNA responding by calling the resident 'crazy' and slamming the bathroom door. The same CNA was later overheard in the dining room loudly making derogatory remarks about the resident, referring to them as 'crazy' and making other disparaging comments within earshot of the resident and others. The incident was corroborated by a witness who provided reassurance to the resident after the verbal exchange. The accused CNA admitted to venting loudly in the dining room but denied using specific derogatory terms in the resident's room. The resident's care plan included the need for a non-confrontational environment due to their psychiatric conditions, but this was not upheld during the incident. The events led to the resident refusing care and expressing distress, with the situation escalating to the point where the CNA left employment after being informed of the abuse allegation.
Failure to Prevent and Document Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure comprehensive documentation and evaluation to prevent the development of an unstageable facility-acquired pressure ulcer for a resident. The resident, who was alert and oriented, was admitted with multiple diagnoses including chronic osteomyelitis, diabetes, and a stage 4 pressure ulcer of the sacral region. Upon readmission, the resident's coccyx/sacrum area was initially documented as moisture-associated skin damage (MASD), but there was no consistent, ongoing assessment or monitoring of the area, leading to the development of an unstageable pressure ulcer. The resident's medical records revealed that the coccyx/sacrum area was not documented on the initial nursing admission assessment, and the order for barrier cream was delayed. Progress notes indicated the area became open with slough and necrotic tissue, eventually developing into a large necrotic unstageable pressure ulcer. The wound was not consistently measured, and there were discrepancies in documentation regarding the wound's status and treatment. Interviews with the wound nurse and nurse practitioner confirmed that the wound began at the facility. The resident reported difficulty turning in bed and prolonged sitting in a recliner, which contributed to the wound's development. The facility's policies on skin inspection and wound care were not adequately followed, as new wounds were not measured within the required timeframe, and there was a lack of documentation on wound progress and treatment plans.
Failure to Follow Transfer Protocols Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure appropriate interventions and supervision were in place to prevent falls with injury for two residents. Resident #44, who had a history of stroke and right-sided weakness, sustained fractures in her right foot during a transfer. The resident was supposed to be assisted by two staff members during transfers, but only one staff member assisted her, leading to her foot not being positioned correctly on a twist board, resulting in fractures. The resident experienced pain and required pain medication and an orthopedic consultation, which led to the use of an electronic lift for transfers. Resident #38, who had a history of a right femur fracture and other mobility issues, was also involved in an incident where the plan of care was not followed. The resident required a two-person assist with a rolling walker for transfers, but was assisted by only one CNA, resulting in the resident being lowered to the floor after slipping. The resident complained of pain in the right knee and leg, and x-rays were conducted to rule out a fracture. The incident led to a decline in the resident's transfer status, necessitating the use of a Hoyer lift. Both incidents highlight a failure to adhere to the residents' care plans, which required two-person assistance during transfers. The CNAs involved did not follow the prescribed care plans, leading to injuries and a decline in the residents' mobility status. The facility's investigation revealed that the staff did not provide the necessary assistance, and the CNAs involved were reprimanded or suspended pending further investigation.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to administer a nebulizer treatment according to professional standards for a resident, as observed during a survey. The nurse prepared the nebulizer treatment for the resident but did not assess the resident's lung sounds or vital signs before administration, nor did she monitor the resident during the treatment. The nurse left the room, and a CNA later discontinued the treatment without informing the nurse. The nebulizer equipment was not properly cleaned or stored, contrary to the facility's policy. Another deficiency involved the administration of medications as prescribed by the physician for two residents. One resident did not receive their inhaler during the medication pass, and the medication was given late. The nurse admitted to starting late and not administering the inhaler, which was left in the medication cart. The facility's clinical supervisor acknowledged that medications should be administered within a two-hour window, but this was not always feasible due to workload. The facility also failed to ensure appropriate diagnosis and use of multiple psychotropic and antipsychotic medications for another resident. The resident was admitted with dementia-related diagnoses and was not on any psychotropic medications initially. However, multiple antipsychotic medications were initiated at the facility without proper informed consent or documentation of non-pharmacological interventions. The resident's behaviors were not consistently documented, and the facility's social services director could not provide a timeline of interventions or explain the rationale for multiple medications.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to implement a comprehensive infection control program, as evidenced by the lack of hand hygiene supplies and inadequate hand hygiene practices. During a tour of the facility, it was observed that there were no hand sanitizer dispensers in the 400-hallway or resident rooms. Staff members were seen entering and exiting resident rooms without performing hand hygiene, and one staff member donned gloves without washing hands. Interviews with residents confirmed that staff did not consistently wash their hands before or after providing care. The facility's infection control program was found to be lacking in process surveillance and data monitoring. The Infection Control Licensed Practical Nurse (LPN) admitted that hand hygiene audits were not properly documented, and there was no process in place for tracking residents with potential infections who were not receiving antibiotics. The facility's Infection Control Committee had not met since the LPN started, and infection control data was only summarized in Quality Assurance meetings without further discussion or analysis. Specific residents were identified with ongoing infections and inadequate infection control practices. One resident with a history of urinary tract infections was found to have a multi-drug resistant organism in their urine. Another resident with a diabetic ulcer did not have access to hand sanitizer near their personal protective equipment. Additionally, catheter care was not performed according to professional standards, with catheter bags being placed directly on the floor. These deficiencies highlight the facility's failure to maintain effective infection prevention and control measures, increasing the risk of infection spread among residents.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent prior to initiating antipsychotic medication for two residents, resulting in the residents and/or their responsible parties not being informed of the risks versus benefits of the medication use before initiation. Resident #25, who has severe cognitive impairment, was started on Seroquel upon admission without documentation of informed consent. Additionally, Clonazepam was initiated for 14 days without any progress notes or assessments, and no consent was present for this medication. Although consents for Seroquel and Paroxetine were eventually obtained, they were dated a week after the resident's admission. Resident #32, also with severe cognitive impairment, was started on Ativan for anxiety without prior notification to the responsible party or the resident. The consent form for Ativan was signed five days after the medication was initiated. An interview with the Director of Nursing confirmed that responsible parties should be informed prior to the initiation of psychotropic medication, and it was noted that the facility had been educating nursing staff to ensure families are informed and documentation is completed. The facility's policy on the use of psychotropic medications requires that residents and/or representatives be educated on the risks and benefits, and the appropriate party sign the consent regarding the medication being given.
Facility Fails to Respect Resident's Guardianship Choice
Penalty
Summary
The facility failed to accommodate a resident's choice in guardianship, leading to distress for the resident. Resident #16, who has full cognitive abilities and requires assistance with all care, was upset because the facility initiated legal action to remove her sister as her guardian and replace her with a public guardian. This action was taken after the resident lost Medicaid eligibility due to excess funds in her account, which occurred when a waiver for Medicaid eligibility expired. The resident's sister, who had been her guardian since 2019, was attempting to purchase a handicap-accessible van for the resident, which contributed to the excess funds. The facility's billing department did not inform the resident or her guardian about the Medicaid ineligibility until three months after it was denied. The guardian made payments towards the outstanding bill, and Medicaid eligibility was eventually restored. However, the facility proceeded with court actions to change the conservatorship due to the unpaid expenses. The facility's interim administrator and billing staff did not communicate effectively with the resident or her guardian about the court proceedings, leading to confusion and distress for the resident, who feared losing her sister as her healthcare guardian. Court documents revealed that the facility requested a specific person to be appointed as the conservator, and the resident's guardian felt blindsided by the facility's actions. The guardian stated that the facility did not adequately communicate the billing issues and that they were attempting to remove her from both conservatorship and guardianship roles. The facility's actions were not aligned with the resident's rights to self-determination and choice, as outlined in the CMS Nursing Home Toolkit, which emphasizes the importance of dignity, respect, and participation in care decisions.
Failure to Update Care Plans for Residents with Falls and Infections
Penalty
Summary
The facility failed to update and revise individualized, person-centered care plans to reflect changing care needs for three residents, resulting in the potential for unmet care needs. Resident #2, who has a history of traumatic brain injury, paraplegia, and severe cognitive dysfunction, experienced multiple falls and hospitalizations due to urinary tract infections. Despite these incidents, the care plans were not updated with new interventions to prevent future falls or address the recurring infections effectively. The care plan for falls had not been revised since 2022, and there was no mention of fall mats or resident alarms, even after multiple falls. Resident #6, diagnosed with Alzheimer's disease and severe cognitive impairment, also experienced several falls without appropriate updates to their care plan. The care plan interventions were not consistently implemented, as observed when the wheelchair was not positioned as required to facilitate safe transfers. The care plan was last updated in June 2024, but it did not reflect interventions for falls that occurred in May 2024. The Director of Nursing confirmed that fall interventions were not in place as required. Resident #32, with severe cognitive impairment and a history of falls, had multiple falls since admission, but the care plans were not updated with appropriate interventions. The interventions listed in the incident reports were not always reflected in the care plans, and some interventions were deemed inappropriate by the Director of Nursing. The facility's policy requires the restorative nurse or designee to investigate incidents and implement additional interventions, but this was not consistently done, leading to deficiencies in care planning and fall prevention.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to provide routine nail care for a resident, resulting in the resident having long, soiled fingernails and long, cracked toenails. During an observation, the resident expressed that she was unable to trim her nails herself and that her granddaughter had attempted to trim some of her toenails but was unable to do so completely due to their length and difficulty. The resident reported that the staff had not assisted her with nail care for some time. The resident's medical history includes kidney failure, right above the knee amputation, a Stage 4 sacral pressure ulcer, weakness, depression, intestinal fistula, colostomy, pulmonary hypertension, and atrial fibrillation. The resident was assessed to have full cognitive abilities and required substantial assistance with hygiene care. The care plan for the resident included interventions for skin integrity and hygiene but did not specifically address nail care. The Director of Nursing acknowledged that nail care should be provided with the resident's shower and mentioned that only nurses or podiatry could assist if the resident was diabetic.
Oxygen Administration and Equipment Storage Deficiency
Penalty
Summary
The facility failed to provide oxygen per the physician's order and did not store nebulizer equipment sanitarily for a resident with respiratory needs. On June 25, 2024, it was observed that the resident's oxygen concentrator was set to 5 liters per minute, despite the physician's order specifying 6 liters per minute. Additionally, the resident's nebulizer mask was found lying face down on the nightstand, which is not a sanitary storage practice. The resident, who had been admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Stroke, and Congestive Heart Failure, required assistance with all Activities of Daily Living and had intact cognition. Further observations on June 27, 2024, confirmed that the oxygen concentrator was still set to 5 liters per minute. An interview with Education Nurse C revealed that the concentrator could not deliver the ordered 6 liters, although the facility had the capability to provide the correct dosage. Subsequently, the physician's order was updated to reflect the 5-liter setting. This deficiency in providing the correct oxygen dosage and improper storage of nebulizer equipment could potentially lead to decreased oxygenation and infection for the resident.
Failure to Coordinate Dialysis Care for Resident
Penalty
Summary
The facility failed to ensure proper coordination of dialysis care for a resident who required such services. The resident, who had a history of stroke, kidney stones, respiratory failure, COPD, diabetes, chronic kidney disease, renal dialysis dependence, morbid obesity, and heart failure, was admitted to the facility with multiple hospital discharges and readmissions. The resident attended dialysis offsite three times a week and was supposed to bring back a packet of papers from dialysis. However, the facility's Hemodialysis Communication Forms often lacked critical information, such as the dialysis access site location and post-dialysis dressing change instructions. Additionally, the forms did not specify the type of dialysis access site or its location, which is essential for proper assessment. The facility's records, including physician orders and the Medication Administration Record, did not mention the resident's dialysis access site. Although the Treatment Administration Record required documentation of the dialysis site assessment within one hour of the resident's return from dialysis, the nurses only documented vital signs without assessing the dialysis site. The Care Plans indicated the need for a post-dialysis assessment, including documentation of the fistula site and signs of bleeding, but this was not consistently done. The Director of Nursing acknowledged the lack of documentation and assessment, noting that the dialysis center nurses were not completing their portion of the assessment on the communication form.
Medication Administration Errors and Delays
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 26.19% error rate. This was due to the omission and untimely administration of medications for two residents. Resident #224 did not receive Protonix 40mg due to it not being available in the facility, and their Symbicort inhaler was not administered during the observed medication pass. Additionally, several medications for Resident #224 were administered late, including Augmentin ES-600 and Calcium Carbonate, which were given over two hours and one hour late, respectively. Resident #322 also experienced delays in medication administration. Medications such as Aspirin EC, Acetaminophen, Omeprazole, Prednisone, Folic Acid, and Lexapro were all administered late. The nurse responsible for administering these medications, Nurse L, acknowledged the delays and attributed them to starting late and not being able to administer the medications on time. The Clinical Supervisor (CS) was interviewed regarding the late medications and indicated that delays were often due to residents not wanting to wake up early or being on leave of absence. The CS also mentioned that the 400 hall was a heavy floor, making it challenging to administer medications within the two-hour window allowed by the facility's policy.
Improper Medication Storage and Handling
Penalty
Summary
The facility failed to properly store medications, including a narcotic medication, during a medication administration task. During an observation, a nurse was seen preparing medication for a resident and placing it in a cup, along with the resident's inhaler, in the top drawer of the medication cart. The nurse then retrieved additional medication from the medication storage room refrigerator. Upon returning, the nurse administered the medications to the resident but did not retrieve or administer the inhaler, which was left in the drawer. Another cup of medications, belonging to a different resident, was also found in the drawer, including Lyrica, a controlled substance. When questioned, the nurse was unaware of the facility's policy regarding the storage of medication in the medication cart and acknowledged that controlled substances should be stored under two locks. The Director of Nursing confirmed that medications should not be left in the cart for extended periods and that narcotics should be stored in a locked narcotic box. A review of the facility's policies indicated that inhalers should be stored in their original boxes and that narcotics must be kept in a locked box on the medication cart or in a medication room.
Inadequate Antibiotic Stewardship and Monitoring
Penalty
Summary
The facility failed to implement a comprehensive antibiotic stewardship and monitoring program, resulting in inappropriate use of antibiotics for two residents. Resident #2, who had a history of traumatic brain injury, paraplegia, and chronic kidney disease, among other conditions, experienced frequent urinary tract infections (UTIs) and was administered multiple antibiotics without effective monitoring. The Infection Prevention and Control (IPC) Nurse A admitted that there was no consistent review of urinalysis or culture and sensitivity (C&S) reports, leading to the resident receiving a variety of antibiotics until a multi-drug resistant organism (MDRO) was identified. The lack of Infection Control Committee meetings and failure to review antibiotic appropriateness with providers contributed to the issue. Resident #21, who had diagnoses including diabetes and heart failure, was also subjected to inappropriate antibiotic use. Despite a urine culture showing no significant growth, the resident continued to receive Ciprofloxacin for the full duration initially prescribed. The IPC Nurse A acknowledged that the antibiotic should have been discontinued after the culture results, but it was not, due to a lack of documentation and oversight. The facility's policy on antimicrobial stewardship, which required antibiotic use and resistance data to be reviewed in IPC meetings, was not followed. The facility's policies on infection prevention and control, as well as antimicrobial stewardship, were not effectively implemented. The IPC Nurse did not routinely document infections or antibiotic use, and there were no Infection Control Committee meetings since February 2024. This lack of oversight and communication with providers led to inappropriate antibiotic use, as evidenced by the cases of Resident #2 and Resident #21. The facility's failure to adhere to its own policies resulted in deficiencies in antibiotic stewardship and monitoring.
Failure to Monitor Hydration and Notify Family
Penalty
Summary
The facility failed to properly assess and monitor the hydration status of a resident, leading to an undocumented administration of intravenous (IV) fluids and a lack of family notification. The resident, who had a medical history including Diabetes Type 2, Dysphagia, and Chronic Kidney Disease, was admitted with a high sodium level indicating dehydration. Despite the physician assistant's order to administer a 1-liter bolus of normal saline, there was no documentation on the amount of IV fluid received or the infusion rate. The resident eventually removed the IV, and there was no record of how much fluid was administered before this occurred. The Director of Nursing (DON) confirmed the absence of documentation regarding the IV fluid administration and acknowledged that the resident's family was not informed about the IV or its removal. The resident was later admitted to the hospital with a diagnosis of Hypernatremia and critical sodium levels. The lack of documentation and communication with the family contributed to the resident's hospitalization.
Failure to Monitor Psychotropic Medication Effects
Penalty
Summary
The facility failed to implement policies and procedures to mitigate potential adverse consequences of psychotropic medications for a resident with dementia. The resident, a 57-year-old male with early onset Alzheimer's disease and other forms of dementia, was admitted to the facility without any psychotropic medications. However, during his stay, he was prescribed multiple psychotropic medications, including Ativan, Haldol, Klonopin, Lexapro, Lurasidone, Olanzapine, Risperdal, and Trazadone. The facility did not conduct baseline laboratory testing or ongoing monitoring to identify potential adverse effects of these medications, which are known to affect liver and kidney function. The resident's health rapidly declined, leading to decreased liver and kidney function, and he was transferred to the hospital multiple times before passing away. The facility's records showed no documentation of baseline or initial monitoring prior to the initiation of psychotropic medications. Interviews with the Assistant Director of Nursing (ADON) confirmed that baseline laboratory tests and EKGs were not completed, and the facility did not typically perform these tests for residents admitted from home. The ADON acknowledged that the facility's policy required consent and education about the risks and benefits of psychotropic medications, but this was not adequately communicated to the resident's family. The family member of the resident expressed concerns about the facility's ability to care for a younger individual with dementia and the lack of awareness about the side effects of the medications. The family member noted that the resident was ambulatory upon admission but became wheelchair-bound and hunched over due to the medications. The facility's failure to conduct necessary baseline testing and provide adequate education and consent contributed to the resident's decline in health and eventual death.
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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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