Shelby Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shelby Township, Michigan.
- Location
- 46100 Schoenherr Road, Shelby Township, Michigan 48315
- CMS Provider Number
- 235506
- Inspections on file
- 32
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Shelby Health And Rehabilitation Center during CMS and state inspections, most recent first.
Multiple residents were unable to reliably request assistance due to a prolonged call light system outage affecting several units. Residents with physical limitations struggled to use the provided hand bells, and staff had difficulty identifying and responding to calls for help, resulting in significant delays in care. Facility documentation and staff interviews confirmed the lack of a formal plan or training to address the outage, and policies requiring timely response to resident needs were not followed.
A kitchenette cabinet under the sink was found to be water-damaged, wet, and covered with a black, mold-like substance. The Administrator and Maintenance Supervisor were previously unaware of the extent of the issue, which was attributed to seasonal humidity. The unsanitary condition was confirmed through observation and complaint review.
A resident with a history of anemia and GI hemorrhage experienced significant changes in condition, including falls, confusion, and behavioral disturbances. Staff responded by administering Haldol for new behaviors rather than promptly assessing the underlying cause or notifying the physician, despite facility policy requiring such notification. This delay resulted in pain and hospitalization for the resident.
A resident with COPD, acute respiratory failure, impaired cognition, and requiring staff assistance was left unsupervised during a nebulizer treatment. The nurse initiated the treatment and left the room without a documented self-administration assessment or care plan, returning to find the resident unresponsive. Facility policy requires supervision during nebulizer treatments unless a self-medication assessment is completed.
The facility failed to maintain proper infection control practices for three residents in isolation. A nurse entered a resident's room without full PPE, and another resident's PPE caddy was inadequately stocked. An LPN did not perform hand hygiene or use PPE when checking a resident's vitals, and equipment was not cleaned as per protocol.
The facility failed to properly store and label medications for two residents and on three medication carts. A resident had a medicine cup with a red liquid on their dresser, identified as a protein supplement, while another resident had vitamin bottles on their nightstand without being assessed for self-administration. Additionally, a partially dissolved narcotic tablet was found on a medication cart, and several insulin pens lacked labels or dates, violating the facility's medication storage policy.
The facility failed to ensure call lights were accessible to six residents, leading to a deficiency. Observations showed call lights were often out of reach or not easily locatable, confirmed by interviews with residents and family members. The residents had various medical conditions and cognitive abilities, requiring different levels of assistance. The facility's policy on call light accessibility was not followed, as confirmed by staff interviews.
A facility failed to obtain a physician's order for an advance directive upon admission for a resident with cerebral infarction and end-stage renal disease. Despite the facility's policy, no advance directive order was found in the resident's records. Interviews revealed a breakdown in the process, with the admitting nurse responsible for entering the order, but it was not completed.
A facility failed to complete an annual PASARR for a resident with vascular dementia, major depressive disorder, and other conditions. The resident's last PASARR was dated several months prior, and the social worker confirmed that an updated PASARR had not been completed, despite the requirement for annual updates. The facility did not provide a policy related to PASARRs by the end of the survey.
The facility failed to update comprehensive care plans for two residents. One resident exhibited increased refusal of care behaviors, but their care plan was not updated to address these changes. Another resident's care plan contained outdated and conflicting information regarding the use of a neck brace and hand splints. The Director of Nursing confirmed the care plans were not updated to reflect the residents' current conditions.
A resident requiring 1:1 feeding assistance due to visual impairment and recent tube feeding discontinuation was left waiting for help with meals on multiple occasions. Observations showed meal trays untouched for extended periods, and the resident expressed hunger and dissatisfaction with cold food. The facility's policy for meal assistance was not followed, as staff failed to provide timely and continuous support.
A resident with a cervical spinal cord injury was not provided with hand splints as ordered, despite multiple observations of the splints being left on a dresser. The resident reported worsening mobility due to neglect, and staff members were unaware of the need for splints. The facility's policy on medical devices was not followed, resulting in a deficiency.
A facility failed to conduct an initial AIMS assessment for a resident prescribed Seroquel, an antipsychotic medication. The resident, diagnosed with Alzheimer's Disease and Brief Psychotic Disorder, required staff assistance with mobility and was unable to complete a mental status assessment. Despite the requirement for quarterly AIMS assessments for residents on antipsychotics, the facility did not perform this assessment. The DON confirmed the necessity of these assessments, and the facility did not provide a policy on antipsychotic use when requested.
A resident with impaired cognition and specific food dislikes was served a meal containing cucumbers, despite a dietary ticket indicating a dislike for them. The resident, who requires assistance with mobility and has a history of Cerebral Infarction and Dysphagia, reported that the kitchen staff often includes cucumbers despite their preference. The Dietary Manager acknowledged that staff should read and highlight tray tickets to ensure preferences are followed, as per facility policy.
A resident with Dementia and other mental health diagnoses did not receive recommended treatment following a hearing consultation. The consulting physician suggested medication to soften impacted ear wax and a follow-up visit, but these recommendations were not noted or executed. The responsible Social Worker acknowledged that the consult and recommendation were missed in the communication process.
A resident on anticoagulant medication experienced a fall with head trauma and was not promptly transferred to the hospital. Despite visible injuries and increased confusion, the facility opted for neuro checks instead of hospital transfer. The resident later had a seizure and was diagnosed with a traumatic subdural hematoma, leading to their death.
Failure to Ensure Timely Resident Care Due to Prolonged Call Light System Outage
Penalty
Summary
The facility failed to meet the timely care needs of six residents due to a prolonged outage of the call light system across multiple units. Residents reported that the call system had been nonfunctional for several weeks to months, and they were instead provided with small hand bells to request assistance. Several residents expressed that the hand bells were difficult to use, especially for those with physical limitations such as numbness in the hands or the need for bilateral wrist and hand splints. In some cases, residents were unable to locate their hand bells or could not bring them into the bathroom, leaving them unable to call for help when needed. Observations and interviews revealed that staff were often unable to hear or identify which resident was ringing a hand bell, leading to significant delays in response times. One resident reported waiting an hour and a half for assistance to use the restroom, while another was observed ringing their bell multiple times without staff response. Staff confirmed the difficulty in distinguishing the source of the bell sounds and noted that they had to physically check each room to determine who needed help. There was also a lack of specific training or program changes implemented to address the outage, and staff were not provided with formal guidance on how to monitor or assist residents during this period. Facility documentation showed ongoing issues with the call light system, including multiple units being affected and no clear timeline for repair. Review of policies indicated that the facility was required to provide accessible call lights and respond in a timely manner, but these standards were not met during the outage. Quality Assurance meeting agendas and education records did not reflect a formal action plan or targeted education regarding the outage, and invoices confirmed ongoing repair attempts without resolution.
Unsanitary Kitchenette Cabinet Due to Water Damage and Mold
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchenette located off the main dining room. On observation, the cabinet under the sink was found to have water-damaged doors, with the particle board swollen and warped from previous water exposure. The bottom shelf of the cabinet was wet, and a black, mold-like substance was present on the surface. The Administrator was unaware of the issue prior to the observation, and the Maintenance Supervisor indicated that the problem was seasonal, related to warmer weather and humidity. These findings were based on a complaint intake and direct observation, confirming the presence of unsanitary conditions in the kitchenette area. No information about specific residents or their medical conditions was provided in relation to this deficiency.
Failure to Promptly Assess and Notify Physician for Acute Change in Condition
Penalty
Summary
The facility failed to promptly identify, assess, and notify a physician regarding an acute change in condition for a resident, resulting in pain and hospitalization. The resident, who was admitted with acute posthemorrhagic anemia and gastrointestinal hemorrhage and had an intact cognitive status on admission, experienced several significant changes in condition, including a fall, confusion, dizziness, low oxygen saturation, and behavioral changes such as combativeness and self-injurious actions. Despite these changes, the facility's response included administering Haldol for new behaviors rather than immediately evaluating the underlying cause or notifying the physician in a timely manner. Documentation revealed that the resident had a foley catheter bag full of blood, experienced multiple falls, and displayed a marked change from their baseline mental status. Staff interviews indicated that these behaviors were not typical for the resident, and there was uncertainty about whether the physician or DON had been notified about the significant findings, such as the blood in the foley bag and the resident's confusion after falls. The facility's policy required notification of the physician and designated representative for significant changes in status, but this was not consistently followed, leading to a delay in appropriate medical evaluation and intervention.
Failure to Supervise Resident During Nebulizer Treatment
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Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, impaired cognition, and requiring staff assistance for bed mobility and transfers, was left unsupervised during a nebulizer treatment. The resident had complained of shortness of breath, and a nurse initiated a nebulizer treatment but left the room, returning ten minutes later to find the resident unresponsive with the face mask off. There was no documentation of a self-administration of medication assessment or care plan in the resident's medical record. Facility policy requires staff to remain with a resident during nebulizer treatments unless a self-medication assessment has determined the resident can safely self-administer. The Director of Nursing confirmed that staff are expected to stay with residents during such treatments or ensure someone else is present if they must leave. The lack of a completed self-administration assessment and the absence of supervision during the nebulizer treatment led to the deficiency.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices for three residents in isolation and precautions. For one resident, a nurse entered the room without donning the required personal protective equipment (PPE) despite clear signage indicating the need for gloves, mask, and gown. The nurse only wore gloves while disconnecting the resident's IV machine, which was against the facility's infection control expectations. This resident had impaired cognition and required assistance with mobility and transfers. Another resident's PPE caddy was consistently found to be inadequately stocked, lacking essential items such as gloves, gowns, and face masks. This resident required assistance for all activities of daily living, including catheter care. Additionally, a Licensed Practical Nurse (LPN) failed to perform hand hygiene and did not use PPE when entering a resident's room to check blood pressure and glucose levels. The LPN also did not clean the equipment after use, contrary to the stated cleaning protocol. The facility's equipment cleaning policy was requested but not provided by the end of the survey.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for two residents and on three medication carts. For one resident, a medicine cup filled with a red liquid was found on their dresser, which the resident believed to be cough medicine. However, the Unit Nurse Manager identified it as a protein supplement and discarded it. The resident's medical record indicated they were moderately cognitively impaired and required maximum assistance for most activities of daily living. Another resident was found with bottles of Vitamin C and Vitamin B-12 on their nightstand, which they claimed to self-administer daily. The Director of Nursing confirmed that this resident had not been assessed for self-administration of medications, indicating a lapse in protocol. Additionally, during a review of medication carts, a partially dissolved narcotic tablet was found in a medicine cup, which had been spat out by a resident. The LPN explained they were waiting for a second nurse to dispose of it properly. Furthermore, several KwikPen Humalog insulin pens were found without labels or dates on two different medication carts. The facility's policy requires accurate labeling and dating of medications, which was not adhered to in these instances. The Director of Nursing confirmed that wasted narcotics should be disposed of immediately with the presence of two licensed nurses, a procedure that was not followed in this case.
Deficiency in Call Light Accessibility
Penalty
Summary
The facility failed to ensure that call lights were accessible to six residents, leading to a deficiency in call light accessibility. Observations revealed that residents' call lights were often out of reach or not easily locatable. For instance, one resident's call light was found on their wheelchair, out of reach, while another resident's call light was located in a shut dresser drawer, making it inaccessible. Additionally, a resident's call light was observed hanging underneath their bed, out of sight and reach. Interviews with residents and family members confirmed these observations, indicating that the issue was recurrent. The residents involved had various medical conditions, including cellulitis, heart failure, sepsis, paroxysmal atrial fibrillation, epilepsy, asthma, Alzheimer's disease, and anxiety. Their cognitive abilities ranged from moderately impaired to intact, with some residents requiring maximum assistance for activities of daily living. The facility's policy on call light accessibility, which mandates that call lights be within reach of residents, was not adhered to, as confirmed by interviews with staff, including a Licensed Practical Nurse and the Nursing Home Administrator.
Failure to Obtain Advance Directive Order Upon Admission
Penalty
Summary
The facility failed to obtain a physician's order for an advance directive upon admission for a resident with cerebral infarction and end-stage renal disease. The resident, identified as having impaired cognition with a Brief Interview for Mental Status score of 8/15, required staff assistance with bed mobility and transfers. Despite the facility's policy requiring the entry of a physician's order for code status upon admission, no such order was found in the resident's medical records. Interviews with facility staff revealed a breakdown in the process of entering advance directive orders. The social worker indicated that the admitting nurse is responsible for entering the code status order, which is then reviewed at the care conference. However, the Director of Nursing was unaware of why the order was not completed for this resident. The facility's policy specifies that a physician's order for Full Code status should be entered into the electronic health record system, but this was not done for the resident in question.
Failure to Complete Annual PASARR for Resident
Penalty
Summary
The facility failed to complete an annual Preadmission Screen and Resident Review (PASARR) for a resident reviewed for PASARR screening. The resident, identified as R121, was observed on March 3, 2025, and had been admitted with diagnoses including vascular dementia, major depressive disorder, hemiplegia and hemiparesis following cerebral infarction, and dysphagia. The resident's medical record showed a Minimum Data Set (MDS) assessment with a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment, and a Patient Health Questionnaire score of 9, indicating severe depression. The last PASARR was dated October 8, 2023, and during an interview on March 5, 2025, the social worker confirmed that an updated PASARR had not been completed, acknowledging that it should be updated annually. The facility did not provide a policy related to PASARRs by the end of the survey.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and updated for two residents, R51 and R89. For R51, the medical record indicated increased behaviors of refusal of care and assistance, such as refusing bathing and assistance weekly during February 2025. Despite these changes, the behavioral care plan initiated in July 2024 was not reviewed or updated to address these increased behaviors. Social Worker C confirmed that no updates were made to the care plan to address the recent behaviors. For R89, the care plan contained outdated and conflicting information. R89, who receives nutrition via tube feeding and is supposed to have hand splints applied, had a care plan that still included a neck brace, which was discontinued after a post-operative appointment in early February. The Therapy Director confirmed the neck brace should have been removed from the care plan, and there was confusion regarding the application of hand splints due to conflicting information. The Director of Nursing confirmed that R89's care plan was not updated to reflect the current condition, and a facility policy addressing care plans was not provided by the completion of the survey.
Failure to Provide Adequate Feeding Assistance
Penalty
Summary
The facility failed to provide adequate feeding assistance to a resident, identified as R142, who required 1:1 feeding assistance due to visual impairment and recent discontinuation of tube feeding. On multiple occasions, R142's meal trays were observed untouched for extended periods, indicating a lack of timely assistance. On March 3, 2025, R142's lunch tray remained untouched for over an hour, and the resident expressed hunger and the need for assistance. Physical Therapy staff noted the resident had not eaten, and R142 later reported that the food was cold by the time assistance was provided, resulting in minimal consumption. Further observations on March 5, 2025, revealed similar issues with breakfast, where R142 waited for assistance to finish their meal. Despite being identified as needing 1:1 feeding assistance, the resident was left waiting, and staff were not immediately responsive to their needs. The Director of Nursing acknowledged that staff should not leave trays unattended and should provide continuous assistance until the resident finishes eating. The facility's policy mandates that residents receive meal assistance according to their individual needs and care plans, which was not adhered to in this case.
Failure to Apply Hand Splints as Ordered
Penalty
Summary
The facility failed to apply hand splints as ordered for a resident, identified as R89, who was observed multiple times lying in bed with their arms folded and hands on their chest, while the prescribed hand splints remained on the dresser across the room. R89, who has an unspecified injury at the cervical spinal cord level and intact cognition, reported that they were supposed to wear the hand splints but that no one ever applied them. The resident expressed that their condition had worsened due to neglect, as they were initially able to move their arms and hands more than they can now. The physician's orders and care plan indicated that the hand splints were to be worn at night and removed in the morning, yet staff members, including an LPN and a CNA, were unaware of the resident's need for hand splints. The Therapy Director confirmed that the splints should be applied at night by nursing staff, as restorative aides are not present during that time. The Director of Nursing acknowledged that applying hand splints is a collaborative effort between nursing and therapy, but the facility's policy on accommodating residents with medical devices was not followed, leading to the deficiency.
Failure to Conduct AIMS Assessment for Resident on Antipsychotic
Penalty
Summary
The facility failed to conduct an initial Abnormal Involuntary Movement Scale (AIMS) assessment for a resident who was prescribed an antipsychotic medication, Seroquel, once daily. The resident, who was admitted with diagnoses of Alzheimer's Disease and Brief Psychotic Disorder, was unable to complete a mental status assessment and required staff assistance with mobility. Despite the requirement for quarterly AIMS assessments for residents on antipsychotics, the facility did not perform this assessment for the resident. During an interview, the Director of Nursing acknowledged that nursing staff should complete AIMS assessments quarterly for residents on antipsychotics, regardless of psychiatric follow-up. Additionally, the facility failed to provide a policy related to antipsychotic use upon request by the surveyors.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as R142, who was reviewed for food preferences. On March 3, 2025, R142's lunch tray was observed with cucumbers in the side salad, despite a dietary ticket indicating a dislike for cucumbers, highlighted in pink. R142 expressed that they do not like cucumbers and that the kitchen staff often includes them despite their preference. R142 was admitted to the facility with diagnoses of Cerebral Infarction and Dysphagia and had an impaired cognition with a Brief Interview for Mental Status score of 10/15. The resident also required staff assistance with bed mobility and transfers. The Dietary Manager, DM Q, stated that dietary staff should read and highlight tray tickets to ensure preferences are seen, and floor staff should check trays before serving them to residents. The facility's policy on Food Preferences and Select Menus states that meals should accommodate resident allergies, intolerances, and food preferences.
Failure to Implement Consultant's Recommendations for a Resident
Penalty
Summary
The facility failed to ensure that a resident received the recommended treatment following an outside consultation. The resident, who was admitted with diagnoses including Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety, was evaluated by a consulting hearing service. The consulting physician was unable to remove impacted ear wax and recommended a medication to soften the wax, with a follow-up visit in 1-3 months. However, this order was not noted or carried out. An interview with the responsible Social Worker revealed that the process for communication involves the Social Worker receiving the completed consult/report, reviewing the documentation, and requesting appropriate orders from the physician or setting up a follow-up appointment. The Social Worker admitted that the consult and the recommendation were missed.
Failure to Ensure Timely Hospital Transfer After Resident Fall
Penalty
Summary
The facility failed to ensure a comprehensive nursing assessment and timely acute care emergent hospital transfer for a resident who sustained a fall with head trauma and bleeding while on anticoagulant medication. The resident, who had quadriplegia and atrial fibrillation, was found on the floor with a bruise on the right eyelid, a superficial scrape on the right forearm, and a skin tear. Despite these injuries and the resident's confusion, the decision was made to conduct neuro checks instead of transferring the resident to the hospital. The resident's medical record indicated that they were on Eliquis, a blood thinner, and had a history of moderate cognitive impairment. After the fall, the resident exhibited increased confusion, which was attributed to a urinary tract infection. The facility's staff, including a nurse practitioner, assessed the resident and decided against hospital transfer, despite the resident's unwitnessed fall and visible head injury. The facility's policy did not specifically address unwitnessed falls for residents on anticoagulant medication. Later, the resident experienced a seizure and was transferred to the hospital, where they were diagnosed with a traumatic subdural hematoma. The resident's condition deteriorated, leading to their death four days later. The facility's failure to promptly transfer the resident to a higher level of care after the fall and head injury, especially given the resident's anticoagulant use, was a significant deficiency in their care.
Latest citations in Michigan
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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