The Laurels Of Coldwater
Inspection history, citations, penalties and survey trends for this long-term care facility in Coldwater, Michigan.
- Location
- 90 N Michigan Avenue, Coldwater, Michigan 49036
- CMS Provider Number
- 235302
- Inspections on file
- 29
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at The Laurels Of Coldwater during CMS and state inspections, most recent first.
A resident with osteomyelitis and multiple stage 4 pressure ulcers of the sacrum, ischium, and hip, who was on hospice and had detailed wound care orders in place, did not have documented routine examinations of these wounds by a licensed medical provider. Wound assessments showed stalled and improving wounds with undermining and tunneling, and an LPN reported that hospice directed treatments focused on comfort and infection control. However, review of progress notes over many months, along with a physician note and a hospice NP face-to-face encounter, showed references to decubitus and non-healing stage 4 ulcers but no documentation that the pressure ulcers were actually examined by a provider, resulting in the cited deficiency.
The facility did not update or revise care plans for multiple residents after incidents of aggression, including altercations between roommates and physical aggression towards a spouse. Despite documented behavioral changes and staff awareness, care plans were not modified to address new risks or interventions, and staff could not provide reasons for these omissions.
A resident with PTSD, anxiety, and a history of physical abuse, who was cognitively intact, was subjected to verbal abuse by a CNA after overhearing staff discuss her care and being accused of faking incontinence. When the resident requested a grievance form and the CNA's name, the CNA refused and responded with profane language, causing emotional distress. The incident was corroborated by another resident and confirmed through staff interviews and facility records.
A resident with severe cognitive impairment and limited upper body control was physically restrained in a wheelchair using a sheet tied by staff, including a CNA and an LPN, to prevent falls. Staff interviews confirmed the restraint was applied for about 15 minutes, and the resident was unable to remove it independently.
Multiple cognitively intact residents reported that meals were consistently unappetizing, cold, or otherwise unpalatable, with some stating they had to supplement with outside food. Surveyors confirmed through direct observation and temperature checks that food was often served outside safe and appetizing temperature ranges, and palatability tests found meals to be bland and unappealing. Facility policies for meal quality and temperature monitoring were not effectively followed, leading to widespread dissatisfaction among residents.
A resident with a signed DNR order was incorrectly listed as full code on the face sheet of the medical record. The discrepancy occurred after the resident returned from the hospital, and staff acknowledged the code status was not updated as required.
Two residents receiving antipsychotic medications were not appropriately monitored for orthostatic hypotension, despite physician orders requiring such monitoring. Review of medical records showed no documentation of orthostatic blood pressure readings for either resident, and the DON confirmed that this monitoring and documentation was expected.
A resident with multiple health conditions and at risk for pressure injuries had a physician's order for protective boots to be worn while in bed, but this intervention was not added to the care plan or the CNA Kardex during the care plan's revision. The DON confirmed the omission despite the existing order.
A resident with multiple chronic conditions did not have a pharmacy medication regimen review recommendation properly followed up. The pharmacy recommended discontinuing loratadine-D due to hypertension, but there was no documented physician response or required signatures, and the DON reported not receiving the recommendation in time to act.
A medication cart was left unattended and unlocked in a hallway with several residents present. An LPN had left the area to use the restroom and forgot to secure the cart, which contained drugs and biologicals. The cart remained unlocked until the LPN returned and was notified of the oversight. Facility policy requires medication carts to be locked when not in use, and the DON confirmed this was not standard practice.
A facility failed to immediately report abuse allegations involving a resident with severe cognitive impairment. An LPN shouted at the resident during an incident, which was witnessed by two CNAs. The incident was not reported to the NHA or State Agency in a timely manner, violating the facility's abuse prohibition policy. The delay in reporting was not addressed through re-education or disciplinary action for the CNAs involved.
The facility failed to maintain clean kitchen equipment, leading to potential foodborne illness risks for residents. Observations revealed fruit flies, sticky floors, soiled sinks, and improperly stored food trays. Dietary staff confirmed inadequate cleaning practices, and pest control services were called due to the infestation. The 2017 FDA Food Code requirements for cleanliness and pest control were not met.
The facility failed to maintain a clean and homelike environment, with several resident rooms and common areas found in unsanitary conditions. A resident's room had a strong odor, stained mattress, and flies, while other areas had peeling paint, loose handrails, and pest issues. Residents were observed in unclean conditions, with dirty wheelchairs and long, unkempt facial hair. Housekeeping staff acknowledged the issues, and the housekeeping manager admitted to not having a documented deep cleaning schedule.
A resident with severe cognitive impairment was found with a bruise of unknown origin near the left eye. The bruise was reported by the resident's family to the DON, but no incident report or investigation was conducted. The Nurse Manager did not complete an incident report, and the DON acknowledged the oversight. The NHA was unaware of the incident until later and confirmed it should have been reported as an allegation of abuse.
A resident with severe cognitive impairment was found with a bruise of unknown origin, which was not investigated or reported as an allegation of abuse by the LTC facility. The DON and Nurse Manager failed to complete an incident report or conduct a thorough investigation, and the Nursing Home Administrator was unaware of the incident until later informed.
A resident with hearing impairments experienced unmet needs due to the facility's failure to implement an effective care plan. Despite having hearing aids, the resident struggled to hear staff, and staff were unaware of the aids' existence. An audiology consult recommended ear drops and irrigation for impacted cerumen, but no physician orders were found, and no cerumen removal was documented.
The facility failed to update care plans for two residents, leading to deficiencies in care management. One resident's care plan did not reflect a dialysis graft in her left arm, causing confusion among staff about her dialysis access. Another resident's care plan was outdated, missing recent diagnoses of pneumonia and rib fractures. Interviews with staff revealed that care plans should have been updated to reflect these changes, but they were not.
Two residents in an LTC facility did not receive adequate hygiene and grooming care. One resident with hemiplegia and reduced mobility was found with unkempt facial hair and dirty fingernails, unsure of the last time he received care. Another resident with major depressive disorder and multiple sclerosis had long facial hair coated in food and a soiled shirt. Both residents' rooms were infested with flies and gnats. Facility records showed refusals of showers without proper documentation or follow-up, and standard grooming care was not consistently provided.
The facility failed to follow physician orders and provide necessary interventions for three residents. A resident with constipation did not receive appropriate interventions despite having a bowel program in place. Another resident with hearing loss was not provided with functioning hearing aids, and no action was taken for impacted cerumen. A third resident did not receive prescribed testosterone injections, with no documentation or physician notification of missed doses.
Failure to Ensure Provider Examination of Stage 4 Pressure Ulcers for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed medical provider routinely examined a resident’s stage 4 pressure ulcers, despite the resident being under hospice care and having multiple complex wounds. The resident was admitted and later readmitted with osteomyelitis of the vertebra, sacral and sacrococcygeal regions, and stage 4 pressure ulcers of the sacral region, right buttock, and left buttock. The resident’s MDS showed moderate cognitive impairment and four stage 4 pressure ulcers, two of which were present on admission or reentry. Wound assessments dated 3/11/26 documented stage 4 pressure ulcers on the left and right ischium, sacrum, and left rear hip, with some wounds described as stalled and others improving, and with undermining and tunneling present. Physician orders were in place for specific wound care treatments, including cleansing, packing, and application of Dakins-moistened gauze and foam dressings. During the survey, the wound care LPN reported that the resident was receiving hospice services and that hospice directed the wound treatments, focusing on comfort and infection control rather than healing. However, review of the resident’s progress notes from 5/1/25 through 3/12/26 did not show documentation that a provider had examined the resident’s stage 4 pressure ulcers during that period. When the surveyor requested the most recent date a provider evaluated the wounds, the facility produced a physician progress note from 6/26/25 and a hospice NP face-to-face encounter note from 2/28/26. Both documents referenced the presence of decubitus ulcers and non-healing stage 4 pressure ulcers, but neither documented an actual examination of the pressure ulcers. This lack of documented provider examination of the resident’s stage 4 pressure ulcers led to the cited deficiency.
Failure to Update Care Plans Following Resident Aggression
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for four out of eleven residents following incidents of aggression or behavioral changes. For one resident with a history of psychosis, insomnia, and major depressive disorder, an altercation with a roommate involving threats and aggressive behavior was documented. Despite this incident, the resident's care plan was not updated to address the new aggression, and no new interventions were added. The last care plan revision occurred months prior to the incident, and no additional care plan addressing aggression towards other residents was found in the electronic medical record. Two other residents were involved in a physical altercation after a disagreement over a room light. Both residents engaged in shoving and striking each other, and one was subsequently moved to another room. However, neither resident's care plan was updated to reflect the aggressive behavior or to include interventions to prevent further incidents. The care plans for both residents had not been revised since before the incident, and no new interventions addressing aggression were documented. Another resident was observed pushing his wife, also a resident, in her wheelchair and using physical force while shouting at her. The incident included yelling, grabbing, and striking, resulting in the wife being moved to another room. Despite this, there was no care plan created or updated to address the resident's aggression or the change in living arrangements. Interviews with facility staff confirmed that care plans should have been updated following these incidents, but the updates were not completed, and staff could not explain why the care plans were missed.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by staff. A resident with diagnoses including PTSD, anxiety, and a history of physical abuse, and who was cognitively intact, overheard two CNAs discussing her care, with one CNA alleging the resident was faking her incontinence. The resident requested a grievance form and asked one of the CNAs for her name, which the CNA refused to provide. The CNA then used profane and abusive language towards the resident, raising her voice and swearing at her. The incident caused the resident emotional distress, and another resident corroborated the account of verbal abuse. Multiple interviews confirmed that the CNA used inappropriate language and refused to provide her name when requested by the resident. The incident was witnessed by another resident and reported by staff, with documentation in the facility's incident and investigation report. The CNA involved had recently completed training on abuse prevention, but still engaged in verbally abusive behavior towards the resident, violating the resident's right to be free from abuse.
Use of Physical Restraint on Cognitively Impaired Resident
Penalty
Summary
Staff failed to ensure that a resident was free from the use of a physical restraint. The resident, who had severe cognitive impairment and multiple medical diagnoses including alcohol-induced persisting dementia, pathological fractures, and anxiety disorder, was observed to have limited upper body control and had experienced multiple falls. On the night in question, staff observed the resident slumped over in a wheelchair, unable to maintain an upright position. In response, a CNA suggested and, with the agreement of an LPN, wrapped a sheet around the resident and tied it to the wheelchair handles to prevent the resident from falling. Another CNA witnessed the resident being tied to the wheelchair and confirmed that the resident could not get out of the restraint, which was in place for approximately 15 minutes. Staff interviews revealed that the decision to use the sheet as a restraint was made out of concern for the resident's safety, despite awareness that such an action constituted the use of a physical restraint and was not in compliance with regulations. The LPN acknowledged that restraints were not permitted but allowed the use of the sheet to prevent a fall. The resident was later returned to bed and remained there until a subsequent fall was discovered. The incident was later confirmed by the facility's administrator during an investigation.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
Surveyors identified a deficiency in the facility's provision of palatable, attractive, and appropriately tempered food and drink to residents. Multiple residents, all cognitively intact per their BIMS scores, reported that meals were consistently unappetizing, cold, or otherwise unpalatable. Observations included residents eating cold cereal, reporting never having received a hot meal or cold milk, and describing the food as 'nasty,' 'horrible,' or 'terrible.' Several residents stated they had to supplement with food from outside the facility due to dissatisfaction with the meals provided. Residents also reported that complaints about food temperature and quality had been made to staff without resolution. Direct observations and palatability tests conducted by surveyors confirmed the residents' reports. Lunch trays sampled during the survey were found to be lukewarm, bland, and lacking in flavor. Specific items such as breaded chicken patties, mashed potatoes, and spinach were described as bland, flavorless, and unappetizing. Food product temperatures were measured and found to be outside the safe and appetizing range, with hot foods served below the required 135°F and cold foods above the required 41°F, as per the 2022 FDA Model Food Code. For example, chef salads and milk were served at temperatures above 41°F, and hot dogs were served below 135°F. Review of facility policies revealed that the facility had established procedures to ensure a pleasant dining experience and proper food temperatures, including periodic test trays and monitoring by nutrition professionals. However, the observations, interviews, and temperature records indicated that these policies were not being effectively implemented, resulting in widespread dissatisfaction and potential nutritional decline among residents who rely on facility-provided meals.
Failure to Accurately Update Advance Directive Status in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive status was accurately reflected in all parts of the medical record. One resident, who was cognitively intact and had multiple diagnoses including respiratory failure, dementia, lung cancer, and COPD, had a Do Not Resuscitate (DNR) order signed and witnessed in the electronic medical record. However, the resident's face sheet, also known as the banner, incorrectly listed the resident as full code rather than DNR. This discrepancy was identified during a record review and interview, where a social service worker acknowledged that the code status had not been updated following the resident's recent return from the hospital.
Failure to Monitor Orthostatic Blood Pressure in Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure appropriate monitoring for two residents who were receiving psychotropic medications. For one resident with vascular dementia and hypotension due to drugs, there was an active physician order for Seroquel, an antipsychotic, with instructions to monitor for side effects including orthostatic hypotension. However, there was no physician order for orthostatic blood pressure readings, and a review of the electronic medical record showed that no orthostatic blood pressures had been documented. The Director of Nursing confirmed that the expectation was to monitor and document orthostatic blood pressures. Another resident with diagnoses including type 2 diabetes, malnutrition, schizoaffective disorder, major depressive disorder, and anxiety was receiving Abilify, an antipsychotic, with a physician order to monitor for side effects such as orthostatic hypotension. The resident was cognitively intact according to the most recent assessment. Despite the order, the medical record did not reflect evidence of routine orthostatic blood pressure monitoring, and the DON stated that such documentation would be found in the vital signs section or progress notes, but none was present.
Failure to Revise Care Plan to Include Physician-Ordered Skin Integrity Intervention
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to include the use of protective boots as ordered by a physician. The resident, who had multiple diagnoses including Alzheimer's dementia, anemia, diabetes, hypertension, bipolar disorder, impaired cognition, incontinence, psychotropic drug use, and protein calorie malnutrition, was identified as being at risk for impaired skin integrity and pressure injury. Although there was a physician's order for the resident to wear specialized boots to both feet while in bed to maintain skin integrity, this intervention was not added to the resident's care plan during its most recent revision. Additionally, the use of the boots was not documented on the Certified Nurse Aid (CNA) Kardex, which serves as the CNA's plan of care. The Director of Nursing confirmed that the boots were not listed on either the care plan or the CNA Kardex, despite the presence of a physician's order. The expectation, as stated by the DON, was that physician-ordered interventions should be reflected in both the care plan and the CNA Kardex.
Failure to Follow Up on Pharmacy Medication Regimen Review
Penalty
Summary
The facility failed to ensure proper follow-up on a monthly pharmacy medication regimen review for one resident. The resident, who had diagnoses including type 2 diabetes, unspecified protein-calorie malnutrition, schizoaffective disorder, major depressive disorder, and anxiety, was cognitively intact according to the most recent assessment. The pharmacy review for this resident dated 1/31/25 included a recommendation to consider discontinuing loratadine-D due to its potential to worsen hypertension, and to consider an alternative antihistamine if needed. However, the pharmacy consultation report did not have a documented response from the physician, nor did it include signatures from the physician or the Director of Nursing (DON). Further review revealed that the recommendation was not followed up on, as the DON reported only receiving the blank pharmacy recommendation after the fact. The lack of documented follow-up and absence of required signatures indicated that the facility did not ensure the pharmacy's recommendation was addressed in a timely manner, as required by policy and procedure.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart located in the 100 hall was observed to be left unattended and unlocked for approximately six minutes, during which time no nurse was present in the area and several residents were seen wandering nearby. The cart contained drugs and biologicals, and it was not secured until an LPN returned and was informed that the cart was unlocked. The LPN stated she had left to use the restroom and forgot to lock the cart. Review of the facility's policy indicated that medication carts are to remain locked except during medication or treatment administration. The Director of Nursing confirmed that leaving the cart unlocked was not consistent with facility policy and that staff are expected to lock the cart when it is unattended.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to immediately report allegations of abuse involving a resident with severe cognitive impairment. On the evening of November 26, 2024, an LPN attempted to assist a resident with a bloody nose in the memory care unit. During the interaction, the resident, who had dementia and scored 3/15 on a mental status exam, became agitated and verbally aggressive. The LPN responded by shouting at the resident, which was witnessed by two CNAs. The incident was not reported to the Nursing Home Administrator (NHA) or the State Agency in a timely manner, as required by the facility's abuse prohibition policy. The CNAs involved reported the incident to the most senior nurse on duty, but it was not escalated to the NHA until the following morning. The facility's policy mandates immediate reporting of abuse allegations to the administrator, but this protocol was not followed. The delay in reporting was not addressed through re-education or disciplinary action for the CNAs involved. The failure to report the incident promptly resulted in a deficiency, as it increased the potential for further unreported abuse allegations.
Facility Fails to Maintain Clean Kitchen Equipment, Increasing Foodborne Illness Risk
Penalty
Summary
The facility failed to maintain clean equipment in the kitchen and dining areas, leading to potential foodborne illness risks for all residents consuming food from the kitchen. Observations revealed numerous fruit flies near the handwashing sink and dishwasher, sticky floors, brown liquid stains on countertops, and soiled sinks with hard water buildup. The cupboards were sticky and warped from water damage, and portable steam table pans contained water and food debris. Food trays were improperly stored on a folding chair, and fruit flies were noted near the sink. In the B dining room kitchenette, similar issues were observed, including soiled countertops, food debris on the plate warmer, and soiled utensils stored in cupboards. The cupboards under the sink were warped and soiled with spider webs and particles. Interviews with dietary staff and management revealed that the steam tables were not cleaned after each use, contrary to the facility's procedures. Pest control services were called due to the fruit fly infestation, and recommendations were made to clean and sanitize the sink and drains, clean the grease trap, and address caulking needs. The Registered Dietician was not involved in assessing the kitchen's condition. The 2017 FDA Food Code was referenced, highlighting the requirement for equipment and surfaces to be clean and free of food residue, and for premises to be maintained free of pests.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in several resident rooms and common areas, as observed during a survey. In one instance, a resident's room was found with multiple cleanliness issues, including a strong foul odor, stained mattress, and floors, as well as the presence of flies and cobwebs. The resident reported frequent urinary incontinence, and despite housekeeping efforts, the room remained unclean over several days. Housekeeping staff acknowledged the persistent odor and stains, and the housekeeping manager admitted to not having a documented deep cleaning schedule. Other rooms and common areas also exhibited significant cleanliness and maintenance issues. Observations included smeared substances resembling blood on walls, peeling paint, loose toilet handrails, sticky debris on floors, and gaps around air conditioners allowing insect entry. Residents reported discomfort and dissatisfaction with the cleanliness and maintenance of their living spaces, including issues with ants and other pests. Additionally, several residents were observed in unclean conditions, with dirty wheelchairs, long and unkempt facial hair, and fingernails caked with debris. Some residents were unsure of when they last received grooming or nail care, and their personal spaces were cluttered and grimy. The presence of houseflies and gnats was noted in multiple rooms, further contributing to the unsanitary conditions.
Failure to Report and Investigate Bruise of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of abuse involving a bruise of unknown origin for a resident with severe cognitive impairment. The resident, who had multiple diagnoses including a stroke, atrial fibrillation, and cognitive communication deficit, was observed with a bruise near the left eye. The resident's family member noticed the bruise and reported it to the Director of Nursing, but did not receive any information about the cause or corrective actions taken. A progress note indicated the bruise was possibly caused by a medical device during care, but no incident report was completed. Interviews with facility staff revealed that the Nurse Manager who documented the bruise did not complete an incident report, believing it was unnecessary. The Director of Nursing acknowledged that an incident report should have been completed and an investigation conducted, but neither occurred. The Nursing Home Administrator was unaware of the bruise until informed by the Director of Nursing, and confirmed that the bruise should have been reported as an allegation of abuse to the appropriate agency.
Failure to Investigate and Report Bruise of Unknown Origin
Penalty
Summary
The facility failed to investigate, implement preventive measures, and take corrective action for an allegation of abuse concerning a resident who was admitted with multiple diagnoses, including severe cognitive impairment. The resident was observed with a bruise of unknown origin on the outer corner of the left eye, which was noted in a progress note. The resident's family member reported the bruise to the Director of Nursing (DON), but no definitive cause or corrective action was communicated to the family. The progress note suggested a possible cause related to repositioning, but no incident report was completed, and the bruise was not investigated further. Interviews with facility staff revealed that the Nurse Manager did not complete an incident report, believing it was unnecessary, and did not conduct a thorough investigation by speaking with other staff members. The DON acknowledged that an incident report should have been completed and an investigation conducted, but neither occurred. The Nursing Home Administrator was unaware of the bruise until informed by the DON and confirmed that the incident was not reported as an allegation of abuse to the appropriate agency.
Failure to Implement Effective Hearing Care Plan
Penalty
Summary
The facility failed to develop and implement an effective care plan for a resident with hearing impairments, resulting in unmet needs. The resident, who was cognitively intact, had a history of hearing loss and was observed struggling to hear staff despite having hearing aids. The care plan included interventions to encourage the use of hearing aids and ensure their functionality, but staff were unaware of the resident's hearing aids and could not locate them. The resident's hearing aids were eventually found, but the resident reported they were ineffective. Further review revealed that the resident had moderate to severe hearing loss and impacted cerumen, which was noted in an audiology consult and an ear care visit. The consult recommended ear drops and ear irrigation for cerumen removal, but there were no physician orders for these treatments, and no documentation indicated that the primary care physician was notified or that any cerumen removal procedure was performed. This lack of action contributed to the resident's continued hearing difficulties.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in their care management. Resident #68, who was admitted with a diagnosis of dependence on renal dialysis, had a care plan that did not reflect the presence of a dialysis graft in her left arm. Despite having a clear dressing on her right chest, staff were confused about the location of her dialysis access, as evidenced by conflicting reports from a CNA and an LPN. The care plan did not include specific instructions regarding the dialysis graft, such as avoiding blood pressure measurements on the arm with the graft, which was crucial for her care. Resident #88, who was readmitted to the facility with multiple diagnoses including pneumonia and rib fractures, had a care plan that was outdated and did not reflect his current medical conditions. The plan of care had not been updated to include his recent fall, which resulted in rib fractures, or his pneumonia diagnosis. Interviews with the Nurse Manager, MDS nurse, and DON revealed that the care plan should have been updated to include these significant changes in his health status, but it was not. The failure to update the care plans for both residents indicates a lapse in the facility's process for ensuring that care plans accurately reflect residents' current medical needs. This deficiency was identified through observations, interviews, and record reviews, highlighting the need for timely and accurate updates to care plans to ensure appropriate care and interventions for residents.
Failure to Provide Adequate Hygiene and Grooming Care
Penalty
Summary
The facility failed to meet the hygiene, grooming, and activities of daily living (ADL) needs for two residents, resulting in unmet care needs. Resident #38, who has hemiplegia, hemiparesis, aphasia, and reduced mobility, was observed with unkempt facial hair, long fingernails, and brown debris under his nails. He was unsure of the last time he received a shower or nail care and did not refuse grooming or nail care. His room was infested with houseflies and gnats, and his wheelchair was dirty. The facility's records showed that Resident #38 had refused all showers for the past thirty days, but there was no documentation explaining the refusals or if alternative care was provided. Resident #86, diagnosed with major depressive disorder, muscle weakness, and multiple sclerosis, was observed with long facial hair coated in food, a soiled shirt, and long fingernails with debris. His room was also infested with houseflies and gnats. He reported that showers were seldom offered, and he had not received assistance with facial hair or nail care. The facility's records indicated that Resident #86 was marked as refusing all offered showers for the past thirty days, with only one progress note documenting a refusal. Interviews with staff revealed that the expectation was to offer showers or bed baths three times, and if refused, nursing staff should be informed, and a note should be entered into the electronic medical record. However, there was a lack of consistent documentation and follow-up on refusals, and standard grooming care was not consistently provided. This resulted in the residents not receiving ADL care according to their individual preferences, with the potential for feelings of shame or embarrassment.
Failure to Follow Physician Orders and Provide Necessary Interventions
Penalty
Summary
The facility failed to follow physician orders and provide necessary interventions for three residents, leading to deficiencies in their care. Resident #27 was readmitted to the facility with multiple diagnoses, including bipolar disorder and type 2 diabetes. Despite having an order for Polyethylene Glycol 3350 for constipation, the resident had not had a bowel movement since readmission, and no interventions were taken. The facility's bowel program, which should have alerted staff after three days without a bowel movement, was not followed, and no bowel protocol was in place. Resident #24, who has a history of hearing loss and uses hearing aids, was observed unable to hear staff despite having a hearing aid in place. The resident's care plan included ensuring the availability and functioning of hearing aids, but staff were unaware of the resident's need for them. An audiology consult had recommended ear drops for impacted cerumen, but no physician order for these drops was found, and the primary care physician was not notified of the issue. Resident #102, diagnosed with paraplegia and major depressive disorder, reported not receiving his prescribed testosterone injections. The medication administration record showed missed doses, with no documentation or notification to the physician about the missed injections. The resident often left the facility, but the medication should have been administered upon return. The facility failed to provide accurate documentation and follow-up on the missed medication, leading to a deficiency in care.
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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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