The Laurels Of Galesburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Galesburg, Michigan.
- Location
- 1080 N 35th Street, Galesburg, Michigan 49053
- CMS Provider Number
- 235483
- Inspections on file
- 28
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at The Laurels Of Galesburg during CMS and state inspections, most recent first.
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.
A resident in an LTC facility, with a history of cerebral infarction and dysphagia, was hospitalized for respiratory distress and unresponsiveness. Despite not being prescribed opioids, the resident tested positive for morphine, suggesting a medication error. The resident's roommate was prescribed morphine, raising concerns about a possible mix-up. The facility's investigation could not confirm how the resident received the opioid, resulting in a deficiency citation.
The facility failed to ensure a dignified environment for residents, with incidents involving staff harassment and inappropriate behavior. A resident felt harassed by a CNA demanding smoking materials, while another incident involved a CNA swearing and slamming a door in front of a cognitively impaired resident. Additional concerns were raised about the rude demeanor of some CNAs, affecting the overall dignity and respect for residents.
A resident with severe cognitive impairment and a history of serious medical conditions was given the wrong medication, leading to a suspected opioid overdose and hospitalization. Despite the incident's severity, the facility did not report it to the State Agency, as the Nursing Home Administrator and DON believed there was no deficient practice to report.
A facility failed to follow physician orders for continuous enteral feeding for a resident, resulting in the feeding being stopped daily against orders. Additionally, the facility did not timely re-weigh the resident after a significant weight change. Another resident experienced a delay in pain assessment and treatment, as staff did not promptly address the resident's complaints of pain. These deficiencies highlight lapses in adhering to professional standards of care.
The facility failed to label and store insulin pens correctly, leading to potential medication efficacy issues. A new nurse was unaware of the labeling policy, and the DON initially miscommunicated the procedure, resulting in insulin pens being improperly managed.
An LPN's lack of specialized dementia care training led to distressing interactions with three residents, resulting in agitation and stress responses. The LPN's unprofessional behavior, including yelling and using profanity, was observed during incidents involving residents with cognitive impairments. The facility's failure to provide comprehensive training contributed to these deficiencies.
The facility failed to meet food safety standards, with improper food storage and labeling observed in various refrigeration units. Cleanliness issues were noted in the kitchen, including debris accumulation and inadequate cleaning of utensils and equipment. The Dietary Manager acknowledged supplier issues and inconsistent staff practices.
The facility failed to protect the potable water supply from plumbing cross connections, risking contamination. A kitchen mop sink was improperly connected to a chemical system, causing back pressure on the faucet's AVB. In the beauty shop, a dish sprayer replaced the hair washing sink's spray, creating a stop downstream of the AVB. The SCU janitor sink's wasting tee was plugged, preventing pressure relief and causing leakage and corrosion.
Two residents in the facility were found without accessible call lights, hindering their ability to request assistance. One resident's call light was out of reach, while another had no call light due to room setup. Staff were unaware of these issues until identified during observations.
A facility failed to update a resident's DNR order timely, resulting in a discrepancy between the resident's preferences and the Electronic Health Record (EHR). The resident, diagnosed with dementia, was listed as a full code in the EHR despite having a DNR order signed by the guardian. The facility's process of updating code status to full code for residents returning from the hospital and delays in document uploads contributed to the issue. Staff interviews revealed a lack of follow-up and no process to ensure pending forms were completed, leading to the failure to update the resident's code status.
A resident's room in the facility was found to be unsanitary, with a persistent fecal odor, gnats, and unclean conditions despite housekeeping efforts. The issues were linked to the roommate's habits of leaving open snacks and drinks, and the facility's failure to address ongoing housekeeping concerns raised in Resident Council Meetings.
A resident with a history of stroke and mobility issues reported missing clothing and had concerns about laundry services. Despite being cognitively intact, the resident did not receive timely follow-up from the facility after submitting a complaint form. The NHA was unaware of the issue, and no grievance form or investigation was documented. A housekeeper admitted to not completing a grievance form, highlighting a failure in the facility's grievance handling process.
The facility failed to notify the State LTC Ombudsman of transfers and discharges since January 2023. The NHA was unaware of the requirement, and the task was neglected after the responsible nurse manager left the facility.
The facility failed to provide written notification of the bed hold policy to two residents upon their transfer to hospitals. One resident with muscle weakness and another with dementia were transferred without receiving the necessary documentation. The Admissions Staff Member responsible for this task admitted to missing it for one resident and was unaware of the other's transfer.
The facility failed to complete PASARR Level II evaluations for two residents with mental health diagnoses, leading to potential unmet mental health care needs. One resident had significant psychiatric conditions and medications, but their Level II evaluation was delayed due to a submission error. Another resident's need for a Level II evaluation was overlooked by the social worker, despite confirmation from the MDS nurse. The facility did not submit the required documentation for comprehensive screening.
The facility failed to develop and implement person-centered care plans for two residents, one with a psychotic disorder and another with pressure ulcers. The absence of a care plan for antipsychotic and antidepressant use for a resident and the lack of proper positioning and protective measures for another resident with pressure ulcers were observed. Staff interviews confirmed the non-implementation of required interventions, despite existing care plans.
A facility failed to follow physician orders for oxygen administration for a resident, resulting in the oxygen being set at 4 liters per minute instead of the prescribed 2 liters per minute. An LPN confirmed the error and noted a lack of communication from the previous shift about any need for increased oxygen. The LPN also acknowledged that any change in oxygen rate required a physician's order, which was not obtained.
The facility failed to have an RN on duty for 8 consecutive hours on specific dates, leading to potential unmet care needs. Interviews and record reviews showed no RN was scheduled or signed in on those days. The NHA and DON did not assess or document the impact on residents, and although RNs were on call, none were present in the building.
A resident with multiple mental health diagnoses and on psychiatric medications did not receive necessary behavioral health care services. The facility failed to develop a care plan for the resident's conditions and medications, and there were no records of psychiatric service visits or behavioral health referrals. Staff interviews revealed that a required PASARR level 2 screening was not completed, and the resident was not referred to psychiatric services as needed.
A facility failed to discontinue a PRN psychotropic medication after 14 days and did not document a rationale for extending its use for a resident with dementia and severe cognitive impairment. The resident had a physician order for Lorazepam, administered as needed for anxiety, with no stop date. The medication was given 10 times in September, and the PA acknowledged the need for a 14-day stop date for reevaluation.
A facility failed to maintain complete documentation in the treatment administration records for a resident with severe cognitive impairment and multiple wounds. Required dressing changes were not documented on several occasions, indicating potential non-compliance with treatment orders. Interviews with staff confirmed that missing documentation implied the tasks were not completed, highlighting a failure in maintaining accurate medical records.
The facility failed to ensure proper hand hygiene and PPE use during enteral feeding and resident showers, leading to potential infection risks. An LPN did not perform hand hygiene or change gloves while administering feeding to a resident, and staff did not adhere to PPE protocols for residents in enhanced barrier precautions during showers. Additionally, shared equipment was not sanitized between uses.
A facility failed to ensure accurate assessments and documentation for three residents, leading to potential health risks. A resident received an insulin injection without a prescription, resulting in sickness and fear. Another resident, prescribed insulin, had inadequate monitoring and documentation of blood sugar levels. A third resident with skin discoloration experienced delayed assessment and documentation. Staff inconsistencies and lack of proper documentation contributed to the deficiency.
The facility failed to protect a resident from verbal and physical abuse by another resident, resulting in fear, increased agitation, and psychiatric hospitalization. In another incident, the facility failed to protect a resident from physical abuse by another resident, despite being aware of the aggressor's history of aggressive behavior.
The facility failed to initiate appropriate treatment measures for a resident with multiple skin integrity concerns, leading to severe health decline and hospitalization. Despite staff observations of swelling, pain, and functional decline, no treatment orders were obtained, and the resident developed sepsis and an ankle abscess requiring multiple surgeries.
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.
Resident Suffers Opioid Overdose Due to Medication Error
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the case of a resident who was transferred to an acute care hospital emergency room for treatment and admission to a medical intensive care unit. The resident, who had a history of cerebral infarction, dysphagia, and acute respiratory failure, was found to have a positive urine drug screen for opioids, despite not being prescribed any opioid medications. The resident's condition deteriorated, leading to respiratory distress and unresponsiveness, which prompted the administration of Narcan, resulting in a full recovery. The investigation revealed that the resident received all nutrition, hydration, and medications through a G-tube and was dependent on staff for all care. The resident's medication administration record indicated scheduled enteral feedings, and there was no record of opioid prescriptions. Interviews with staff members, including LPNs and the DON, confirmed that the resident did not receive any narcotic medications during the shift, and there were no discrepancies in the narcotic count. However, the resident's urine drug screen was positive for morphine, raising concerns about a possible medication error. Further investigation highlighted that the resident's roommate was prescribed morphine sulfate, and there was a possibility of medication mix-up due to the similarity in appearance between liquid Tylenol and morphine sulfate. Despite the facility's efforts to identify the source of the opioid exposure, the investigation was unable to confirm how the resident received the opioid, leading to the deficiency citation for failing to ensure residents were free from significant medication errors.
Deficiency in Resident Dignity and Respect
Penalty
Summary
The facility failed to provide a dignified environment and ensure that staff treated residents with dignity and respect, as evidenced by multiple incidents involving staff interactions with residents. One incident involved a resident who felt harassed by a CNA who persistently demanded her smoking materials, leading to a verbal altercation. The resident, who was moderately cognitively impaired, expressed feeling targeted and upset by the CNA's behavior, which was corroborated by other staff members who witnessed the incident. Another incident involved a CNA who was observed swearing and slamming a door in the presence of a severely cognitively impaired resident. Although the resident's ability to comprehend the situation was limited, the behavior was deemed inappropriate and unprofessional. Staff members reported feeling unsafe and concerned about the CNA's unpredictable behavior, which had been an ongoing issue. Additional concerns were raised by residents and staff about the general demeanor and attitude of some CNAs, who were described as rude and unapproachable. Residents reported feeling like an inconvenience when asking for assistance, and staff noted that some CNAs did not provide adequate care, particularly to residents who were unable to voice their concerns. These issues contributed to an environment that did not respect or enhance the dignity of the residents.
Failure to Report Medication Error and Resulting Hospitalization
Penalty
Summary
The facility failed to report an incident of neglect involving a resident who received the wrong medication, leading to a serious medical emergency. The resident, who had a history of cerebral infarction, dysphagia, acute respiratory failure with hypoxia, and pneumonitis, was found to be severely cognitively impaired. On the evening of the incident, the resident was observed to be very drowsy with increased secretions, and vital signs indicated respiratory distress. The resident was transferred to an acute care hospital emergency room, where they were treated with Narcan for a suspected opioid overdose, despite not being prescribed any opioid or narcotic medication. Subsequent drug tests confirmed the presence of morphine in the resident's system. Despite the severity of the incident, the facility did not report the event to the State Agency. The Nursing Home Administrator and Director of Nursing both concluded that there was no deficient practice to report, as they determined that narcotics were not missing and believed the hospital would notify the state. This lack of reporting was a failure to comply with the requirement to report suspected abuse, neglect, or theft, and the results of the investigation to the proper authorities, as the resident's hospitalization and positive drug screen were not communicated to the state agency.
Failure to Follow Physician Orders and Address Pain Timely
Penalty
Summary
The facility failed to ensure that Resident #101 received enteral feeding in accordance with physician orders. Resident #101 was admitted with a diagnosis of dementia and required continuous enteral feeding through a G-tube due to dysphagia. However, the nursing staff, including LPN L and RN G, were not aware of the updated continuous feeding order following the resident's hospital readmission. As a result, the tube feeding was stopped daily between 10:00 AM and 2:00 PM, contrary to the physician's orders. This oversight was confirmed by multiple staff members, including the Unit Manager and the Physician Assistant, who expected the continuous feeding order to be followed. Additionally, the facility did not timely re-weigh Resident #101 after a significant weight change was noted. The resident's weight increased by 13 pounds within 22 days, which constituted an 8.64% change. Despite this significant change, the facility's dietician and interdisciplinary team failed to identify and report the weight change, and no re-weight was conducted to confirm the accuracy of the initial measurement. The facility's policy required re-weights for significant changes, but this was not adhered to, as confirmed by the Director of Nursing and the Registered Dietician. Resident #103 experienced a delay in pain assessment and treatment. Despite showing signs of pain and indicating discomfort by pointing to his ribs, the resident was not assessed or provided pain medication in a timely manner. LPN L was informed of the resident's pain at 11:40 AM but did not assess or administer pain relief until after 1:15 PM. The Nursing Home Administrator acknowledged that the delay in addressing the resident's pain was not in line with the facility's expectations for prioritizing and managing residents' pain complaints.
Failure to Properly Label and Store Insulin Pens
Penalty
Summary
The facility failed to properly label, date, and store medications, specifically insulin pens, in one of the two medication carts reviewed. During an interview, a Registered Nurse (RN) expressed concerns about the lack of labeling on insulin pens when opened, which was not addressed adequately by the Director of Nursing (DON). The DON had instructed nurses to contact the pharmacy to determine the delivery date of the insulin pens, which was not an accurate method to ascertain when the pens were opened. This led to confusion and inefficiency in determining the usability of the insulin pens. Observations revealed that insulin pens in the medication cart were either not labeled with the date they were opened or were stored improperly. A new nurse was unaware of the facility's policy on labeling insulin, indicating a lack of proper training or communication. Further interviews confirmed that the insulin pens without labels were unsafe for use and should be discarded. The Unit Manager confirmed that the facility expected nurses to label and date insulin pens upon opening and to keep them refrigerated until needed. The DON later acknowledged the expectation for nurses to date the pens when opened, highlighting a miscommunication in the facility's procedures.
Inadequate Dementia Care Training Leads to Resident Distress
Penalty
Summary
The facility failed to ensure that three residents with dementia were treated in a manner that supported their psychosocial wellness, leading to avoidable stress responses. Resident #101, who was cognitively impaired with a BIMS score of 7/15, experienced agitation after an LPN entered her room and spoke to her in an emotionally charged tone. The LPN's lack of specialized dementia care training contributed to the resident's negative response, as she became agitated and unsafe after the interaction. Resident #102, also cognitively impaired with a BIMS score of 6/15, was subjected to aggressive behavior from the same LPN. The LPN, appearing stressed, yelled at the resident after being physically contacted by her. This interaction led to the resident becoming agitated and pulling a fire alarm. The LPN admitted to being overwhelmed and acknowledged her unprofessional behavior, which was exacerbated by insufficient dementia care training. Resident #103, with a BIMS score of 10/15, was involved in an incident where the LPN, frustrated by the resident's bowel incontinence, used profanity while providing care. This behavior left the resident quiet and withdrawn. The LPN admitted to ranting about the situation, indicating a lack of appropriate response to the resident's needs. The facility's failure to provide comprehensive dementia care training contributed to these incidents, as the LPN was not adequately prepared to handle the residents' behaviors effectively.
Deficiencies in Food Safety and Cleanliness
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of improper food storage and labeling. During a kitchen tour, surveyors found a container of sliced turkey, an open gallon of milk, and a container of hot dogs in the reach-in cooler without proper discard dates. Additionally, thawed Mighty Shakes and Magic Cups were found without discard dates, despite their packaging indicating specific time frames for consumption. Similar issues were observed in the Activity refrigeration units and the SCU dining room, where items like thickened lemon water and med pass 2.0 were not properly dated, and chocolate milk was stored past its best-by date. Interviews with the Dietary Manager revealed that there were issues with supplier deliveries and that staff were responsible for dating items, but this was not consistently done. The facility also exhibited significant cleanliness and maintenance issues in the kitchen and surrounding areas. Observations included an accumulation of crumbs, dirt, and various debris around the ice machine, juice machine, and cooler areas. The walls near the juice machine were stained with orange splash and debris due to a leak. Further inspections revealed dirt and grime around the dish machine line, cook line corner, and hand sink, with some areas having loose or missing vinyl coving, which compromised the ability to maintain cleanliness. Dusty debris was also found on lights over the preparation and cook line area, and a ceiling vent and tower fan were covered in dust and debris. Additional deficiencies were noted in the handling and storage of kitchen utensils and equipment. Clean utensils were stored in colander pans that contained crumbs and plastic debris, and the frequency of cleaning these pans was uncertain. The inside of the microwave had dried debris accumulation, and the juice dispenser spout was not adequately cleaned. Sheet pans on the drying rack were greasy and had carbon accumulation, and the ice scoop holder in the ice room contained slimy debris. These observations indicate a failure to maintain equipment and food-contact surfaces in a clean and sanitary condition, as required by the FDA Food Code.
Failure to Protect Potable Water Supply
Penalty
Summary
The facility failed to properly protect the potable water supply from plumbing cross connections, which could potentially lead to increased illness and contamination of the domestic water. During a tour of the kitchen, it was observed that the mop sink in the janitors' closet was left on and connected to a pre-dispense chemical system. This setup placed undue back pressure on the faucet's internal atmospheric vacuum breaker (AVB), which is not approved for constant back pressure. In the beauty shop, the hair washing sink's spray was replaced with a kitchen dish sprayer that controls pressure with a thumb valve, creating a stop downstream of the faucet's AVB. The sprayer was found lying in the bottom of the sink near the drain. Additionally, the SCU janitor sink's wasting tee was plugged, preventing the device from relieving undue back pressure on the faucet's internal AVB, which was also observed to be leaking with visible heavy corrosion.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were available and within reach for two residents, resulting in their inability to call for staff assistance. Resident #84, who was admitted with diagnoses including difficulty in walking, muscle weakness, and dementia, was found to have a call light that was either on the ground or out of reach on two separate occasions. Despite being encouraged to use the call light for assistance, Resident #84 was unable to do so due to its inaccessibility. This was confirmed by a Certified Nursing Assistant (CNA) who acknowledged the call light was out of reach. Similarly, Resident #75, who was admitted with dementia, did not have a call light in his room at all. During observations, it was noted that the room setup only allowed for one call light, which was being used by the roommate. Staff, including a CNA, LPN, and a Physician Assistant, were unaware of the absence of a call light for Resident #75, despite his need for assistance due to anxiety and frequent visits to the nurse's station. The Nursing Home Administrator confirmed the deficiency and indicated that maintenance would be contacted to address the issue.
Failure to Update DNR Order Timely
Penalty
Summary
The facility failed to ensure an accurate do not resuscitate (DNR) order was updated timely for a resident, resulting in the potential for the resident's preferences for medical care to not be followed. The resident, who was originally admitted with a diagnosis of dementia, was noted as a full code in the Electronic Health Record (EHR), despite having a DNR order signed by the guardian. The discrepancy arose because the facility updated the code status to full code for residents returning from the hospital until their re-admission paperwork was signed and scanned into the EHR. The resident returned from the hospital, and the facility was behind on uploading documents, leading to the outdated code status in the EHR. Interviews with facility staff revealed that the social worker was responsible for verifying the accuracy of resident code status at care conferences, but the resident's code status was not updated after a care conference that discussed the resident's desire to be noted as DNR. The medical records staff had requested the updated DNR form from the resident's guardian but had not received it back and did not follow up. There was no process in place to ensure pending forms were completed and received back, which contributed to the failure to update the resident's code status in a timely manner.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for a resident, resulting in potential dissatisfaction with living conditions. The resident, who was cognitively intact and had diagnoses of anxiety, depression, and paranoid schizophrenia, was found in a room that smelled like feces, with a dried-up red spill on the floor and a dusty hairbrush under the bed. Despite housekeeping efforts, the room continued to smell, and gnats were observed flying around the resident's bedside table, bed, and curtain divider. The presence of gnats was attributed to open snacks and drinks left by the resident's roommate. The Resident Council Meeting Minutes from previous months indicated ongoing concerns about housekeeping, specifically regarding items left under beds and inadequate cleaning. Interviews with the Nursing Home Administrator and a Licensed Practical Nurse confirmed awareness of the issues, including the persistent odor and presence of gnats. The administrator acknowledged the challenges posed by the roommate's habits, such as refusing to be changed and keeping unfinished drinks, which contributed to the unsanitary conditions in the room.
Failure to Address Resident Grievance Timely
Penalty
Summary
The facility failed to address a resident's grievance in a timely manner, resulting in feelings of frustration and anger for the resident. The resident, who had a history of cerebral infarction and difficulty walking, reported missing clothing items and had concerns about his clothes returning from the laundry. Despite being cognitively intact, as indicated by a BIMS score of 14/15, the resident had not received any follow-up from the management team regarding his missing clothing, even after completing a complaint form over a week prior. The Nursing Home Administrator (NHA) was unaware of the resident's concerns and could not provide any documentation of a grievance form or investigation into the missing clothing. A housekeeper acknowledged being informed by the resident about the missing items but did not complete a grievance form. The NHA stated that staff members are expected to complete a concern form or provide one to the resident when a concern is raised. However, no grievance forms were found for the resident, indicating a failure in the facility's grievance handling process.
Failure to Notify Ombudsman of Transfers/Discharges
Penalty
Summary
The facility failed to provide written notification to the State Long-Term Care Ombudsman regarding facility-initiated transfers and discharges since January 2023. This deficiency was identified through an email from the Ombudsman, which indicated that the required notices had not been received. During an interview, the Nursing Home Administrator (NHA) admitted to being unaware of the regulation requiring such notifications and was uncertain about the facility's process for notifying the Ombudsman. It was revealed that a nurse manager, who was previously responsible for sending these notices, had left the facility, and the task was not reassigned, resulting in the oversight.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives upon discharge to an acute care hospital. This deficiency was identified for two residents who were transferred to hospitals for emergency care. Resident #8, who had a diagnosis of muscle weakness, requested to be sent to the hospital, and the transfer was facilitated by a physician assistant and emergency medical services. However, a review of Resident #8's electronic health record did not reveal any documentation of a bed hold policy being provided upon discharge. Similarly, Resident #17, who had a diagnosis of dementia, was transferred to a psychiatric hospital, but there was no documentation of a bed hold policy being provided. During interviews, the Admissions Staff Member responsible for ensuring the distribution of bed hold policies admitted to missing the task for Resident #17 and was unaware of Resident #8's transfer. The Nursing Home Administrator confirmed that the Admissions Staff Member was responsible for this task, which had not been completed.
Failure to Complete PASARR Level II Evaluations
Penalty
Summary
The facility failed to ensure the completion of the Preadmission Screening and Resident Review (PASARR) Level II evaluations for two residents, resulting in potential unmet mental health care needs. Resident #77, who was admitted with diagnoses including schizophrenia, unspecified psychosis, major depressive disorder, generalized anxiety disorder, and insomnia, was receiving significant psychiatric medications. Despite having a Level I PASARR screening indicating mental illness, there was no Level II screening in the resident's record. Interviews revealed that the PASARR Level II was stuck in a queue and had not been submitted to OBRA as required. The medical records staff only notified the provider about the need for a Level II evaluation after the survey inquiry. Similarly, Resident #27 was admitted with diagnoses of depression, mild cognitive impairment, adjustment disorder with mixed anxiety and depression, and psychotic disorder with delusions. The resident's PASARR Level I screening indicated the need for a Level II evaluation due to mental illness, but it was not completed. The social worker incorrectly stated that the resident did not meet the criteria for a Level II evaluation, while the MDS nurse confirmed the need for it. The facility's failure to submit the necessary documentation to the local Community Mental Health Service Program for a comprehensive Level II screening contributed to the deficiency.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans for two residents, leading to potential unmet care needs. Resident #44, who was admitted with diagnoses of depression, anxiety, mild cognitive impairment, and a psychotic disorder, did not have a care plan addressing their psychotic disorder or antidepressant use. The social worker responsible for completing these care plans confirmed the absence of such plans in the resident's chart. Resident #36, diagnosed with dementia and pressure ulcers on the sacrum and both heels, was observed multiple times without proper positioning or protective measures in place. Despite having a care plan that included interventions like repositioning every two hours and using prevalon boots to protect the heels, these measures were not implemented. Observations showed the resident's heels and sacrum were in direct contact with the mattress, and the protective boots were not being used as required. Interviews with facility staff, including a CNA, LPN, DON, and RN, revealed that the expected care plan interventions for Resident #36 were not being followed. Staff acknowledged the resident's dependency on them for repositioning and the necessity of using heel protectors, yet these interventions were not consistently applied. The facility's care planning policy emphasizes the development and implementation of person-centered care plans based on comprehensive assessments, which was not adhered to in these cases.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders for the administration of oxygen to a resident, leading to incorrect oxygen settings. Resident #81, who was admitted with a diagnosis of adult failure to thrive, had an order for oxygen to be administered at 2 liters per minute via nasal cannula as needed for shortness of breath. However, during observations on two consecutive days, the resident's oxygen was found to be running at 4 liters per minute, which was not in accordance with the physician's order. An LPN confirmed the discrepancy and admitted to not being aware of the incorrect oxygen rate, as she had not checked on the resident that day. Furthermore, the LPN reported that there was no communication from the evening nurse regarding any changes in the resident's condition that would necessitate an increase in oxygen. The LPN also confirmed that any change in the oxygen rate required a new order from the physician, which had not been obtained.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours on specific dates, namely 4/13/2024, 4/27/2024, 5/25/2024, and 5/26/2024. This deficiency was identified through interviews and record reviews, which revealed that no RN was scheduled or signed in on these dates. The PBJ Report indicated staffing concerns, highlighting the absence of RN coverage for 8 consecutive hours during the third quarter of 2024. General and Administration (GA) GG admitted to not scheduling an RN on the mentioned dates, citing a shortage of RNs at the time. Although the facility has since increased its RN staff, there was no RN coverage on those specific days. Interviews with the Nursing Home Administrator (NHA) A and the Director of Nursing (DON) B revealed a lack of assessment and documentation regarding the impact of the RN coverage deficiency on residents. NHA A acknowledged the issue but was unable to provide evidence of discussions or evaluations related to the deficiency during Quality Assurance Performance Improvement (QAPI) meetings. Additionally, DON B confirmed that no assessments were conducted to determine if residents were affected by the lack of RN coverage. Despite having RNs on call, there were no RNs physically present in the building on the specified dates.
Failure to Provide Behavioral Health Care Services
Penalty
Summary
The facility failed to provide necessary behavioral health care services to a resident with multiple mental health diagnoses, including schizophrenia, unspecified psychosis, major depressive disorder, generalized anxiety disorder, and insomnia. Despite being prescribed several psychiatric medications such as Aripiprazole, Trazodone, Venlafaxine, Zyprexa, and Clonazepam, the resident did not have a care plan developed for these conditions or medications. Additionally, there were no records of psychiatric service visits, social service notes, or behavioral health referrals in the resident's health records. Interviews with facility staff revealed that the resident had a Preadmission Screening and Resident Review (PASARR) level 1 indicating mental illness, but a level 2 screening was not completed. The MDS Nurse acknowledged that the PASARR level 2 was pending submission since May 2024. The Social Worker confirmed that the resident should have been seen by psychiatric services monthly and should have had a care plan in place, but these actions were not taken. The Director of Nursing agreed that the resident required a care plan and behavioral health services, but these were not implemented upon admission.
Failure to Discontinue PRN Psychotropic Medication After 14 Days
Penalty
Summary
The facility failed to discontinue the use of psychotropic medications prescribed as needed (PRN) after 14 days and did not document a rationale for extending the PRN use for a resident reviewed for unnecessary medications. This deficiency involved a resident who was admitted with a diagnosis of dementia and had a severely impaired cognitive status, as indicated by a Brief Interview for Mental Status (BIMS) score of 6/15. The resident had a physician order for Lorazepam, a psychotropic medication used as a sedative, to be administered every four hours as needed for anxiety, with no specified stop date. The medication was administered 10 times in September, and the order was written by a Physician Assistant (PA). During an interview, the PA acknowledged that the order should have included a 14-day stop date to ensure reevaluation of the resident's condition.
Incomplete Documentation in Treatment Administration Records
Penalty
Summary
The facility failed to ensure complete documentation in the treatment administration records (TAR) for a resident with severe cognitive impairment and multiple wounds, including pressure ulcers on the sacrum and both heels. The resident's treatment orders required specific wound care procedures to be documented in the TAR, but several instances of missing documentation were identified. For example, there was no documentation for certain dates in July, August, and September, indicating that the required dressing changes may not have been completed as ordered. Interviews with facility staff, including an LPN, the Director of Nursing (DON), and an RN, confirmed that if the TAR was left blank, it indicated that the task was not completed. The DON and RN both stated that their expectation was for the TAR to be completed when dressing changes were performed, and if not signed, it implied the treatment did not occur. This lack of documentation suggests a failure in maintaining accurate medical records in accordance with professional standards, potentially impacting the resident's care.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to ensure proper hand hygiene and use of personal protective equipment (PPE) during the administration of enteral feeding for a resident with severe cognitive impairment and multiple gastrointestinal conditions. An LPN was observed preparing medications and a bolus feeding for the resident without performing hand hygiene or applying PPE before entering the resident's room. The LPN used the same gloves throughout the procedure, including when adjusting the resident's bed, obtaining tap water, and administering medications and feeding through the resident's PEG tube. The LPN also used an ink pen from her pocket to puncture the formula bottle, further compromising infection control protocols. Additionally, the facility did not ensure the proper use of PPE by staff for residents in enhanced barrier precautions during showers. A CNA was observed transporting a resident to the shower room without wearing any PPE, despite signage indicating the need for enhanced barrier precautions. Interviews with staff revealed a lack of adherence to PPE protocols during resident showers, with some staff unaware of the requirements or failing to reapply PPE when necessary. The absence of PPE storage in the shower rooms contributed to this deficiency. The facility also failed to sanitize resident-shared equipment between uses, as observed when a mechanical lift was not cleaned after being used for a resident in enhanced barrier precautions. The DON provided education to a CNA about the need for PPE but did not sanitize the equipment before leaving it in the hallway. Interviews with staff, including the DON and the Infection Preventionist, highlighted an education gap regarding enhanced barrier precautions and the expectation that shared equipment should be sanitized after each use.
Failure to Ensure Accurate Assessment and Documentation
Penalty
Summary
The facility failed to ensure a complete and accurate assessment for three residents, leading to potential health risks. Resident #101, who was cognitively intact, reported receiving an insulin injection from RN F despite not having a prescription for insulin. The resident experienced sickness after the injection and expressed feelings of anger and fear. The facility's records showed no physician order for insulin for Resident #101, and the nurse involved denied administering the injection. The investigation revealed inconsistencies in the documentation and monitoring of the resident's condition following the alleged medication error. Resident #110, who shared a room with Resident #101, was prescribed insulin for diabetes management. The facility's records indicated that both residents had their blood sugars checked, but there was a lack of documentation regarding the monitoring and assessment of their conditions after the incident. The Director of Nursing (DON) and other staff members acknowledged the absence of proper documentation and monitoring, which should have included skin assessments and blood sugar monitoring for three days. Resident #100, who had multiple diagnoses including Alzheimer's disease and was a hospice patient, was found to have skin discoloration under her breast. The incident was reported by a CNA, but there was a delay in proper assessment and documentation by the nursing staff. Interviews with staff revealed that the discoloration was noticed by several aides, but the information was not promptly communicated to management or documented in the resident's records. The facility's failure to document and investigate the skin discoloration in a timely manner contributed to the deficiency.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect Resident #100 from verbal and physical abuse by another resident, Resident #102. Resident #100, who was severely cognitively impaired and had diagnoses including anxiety disorder and major depressive disorder, was found injured on the bathroom floor after being pushed by Resident #102. Multiple staff members, including CNAs and LPNs, reported witnessing Resident #102 verbally abusing and threatening Resident #100 on several occasions prior to the incident. Despite these reports, no action was taken to separate the residents or address the ongoing conflict, resulting in Resident #100 experiencing fear, increased agitation, and requiring inpatient psychiatric hospitalization. In another incident, the facility failed to protect Resident #102 from physical abuse by Resident #101. Resident #102, who was also severely cognitively impaired, was punched in the face by Resident #101 outside the activity room. Staff members reported that Resident #101 had a history of becoming verbally and physically aggressive, especially in crowded areas. Despite this known behavior, Resident #101 was not adequately monitored or separated from other residents, leading to the physical altercation with Resident #102. Both incidents highlight the facility's failure to take appropriate measures to prevent resident-to-resident abuse, despite being aware of the ongoing conflicts and aggressive behaviors. The lack of timely intervention and appropriate room assignments contributed to the physical and emotional harm experienced by the residents involved.
Failure to Initiate Appropriate Treatment Measures
Penalty
Summary
The facility failed to initiate appropriate treatment measures for Resident #100, who was admitted with multiple skin integrity concerns, including a skin tear on his right lower leg. Despite the facility's policy requiring notification of the resident's practitioner for any change in status, no treatment orders were obtained for Resident #100's skin tears from 2/8/24 to 2/21/24. Licensed Practical Nurse (LPN) J reported that the absence of a Unit Manager led to a lapse in obtaining necessary treatment orders, and although she wrapped the wound in gauze, it did not stay in place. Other staff members, including LPN Q and LPN V, confirmed that it was the nurse's responsibility to notify the provider for treatment orders, but this was not done for Resident #100's skin tears. Resident #100's condition deteriorated significantly upon his return to the facility. Competency Evaluated Nursing Assistants (CENAs) P, D, and R observed that Resident #100's right lower leg was swollen, painful, and that his functional abilities had declined. Despite these observations and reports of increased pain, no appropriate medical intervention was initiated. The Wound Care Physician (MD) T and Nurse Practitioner (NP) S were not alerted to the resident's condition, and no orders for wound care were documented until 2/22/24. By this time, Resident #100's condition had worsened, leading to a large draining wound on his ankle. On 2/13/24, LPN K noticed the severity of Resident #100's condition and reached out to the provider, resulting in an ultrasound order to rule out a deep vein thrombosis. However, the ultrasound was not completed before Resident #100 was transferred to the hospital on 2/14/24. At the hospital, Resident #100 was diagnosed with sepsis, an ankle abscess, and other serious conditions, requiring multiple surgical interventions. The facility's failure to follow its own policies and obtain timely treatment orders directly contributed to the resident's severe health decline and subsequent hospitalization.
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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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