The Laurels Of Sandy Creek
Inspection history, citations, penalties and survey trends for this long-term care facility in Wayland, Michigan.
- Location
- 425 E Elm St, Wayland, Michigan 49348
- CMS Provider Number
- 235313
- Inspections on file
- 28
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at The Laurels Of Sandy Creek during CMS and state inspections, most recent first.
The facility failed to maintain its roof and ceilings, leading to extensive leaks, stained and deteriorating ceiling tiles, rusted light fixtures, and moisture-damaged walls across multiple halls, nurses’ stations, medication rooms, and spa areas. One cognitively intact resident had to be moved from a preferred room after prolonged roof leaks caused a large stained area near a light fixture and disrupted use of the room, while another resident with chronic pain, depression, and moderate cognitive impairment slipped and fell on water that had leaked from the roof onto his room floor. Staff, including CNAs, an LPN, and the former DON, reported that the roof had been leaking for many months to over a year, that residents and their belongings were repeatedly exposed to water, that residents were frequently relocated due to leaks, and that water sometimes dripped on residents in shower rooms.
Two residents were subjected to abuse by nursing staff. In one case, a cognitively intact resident and his roommate reported that an RN, during a night shift interaction about oxygen use, cursed at the resident, stated "I hate you," and made an obscene gesture, which the facility’s own documentation identified as verbal abuse. In the second case, a resident with dementia, chronic pain, anxiety, and a history of pacing and anxiety-related behaviors was confronted by an LPN while she stood at a med cart. Witnesses reported that the LPN escalated the situation, grabbed the resident’s wrists, forced her arms behind her back in a painful position, slammed her into doors, took her into her room amid loud banging and the resident’s cries that she was being hurt and could not breathe, and repeatedly slammed the door on the resident as she tried to exit, while yelling at her and threatening to fight her. The resident was later observed crying, shaken, and disheveled, and reported that the LPN had choked and thrown her down. Facility leadership substantiated that verbal abuse occurred in the first case and verbal and physical abuse occurred in the second, demonstrating a failure to keep residents free from abuse by staff.
A resident with chronic pain, anxiety, and dementia became agitated and was pacing when an LPN told the resident to go to their room and stay there; after the resident refused and attempted to strike the LPN, the LPN placed the resident’s arms behind their back, physically moved the resident to the room, and closed the door, during which the resident said, “stop that hurts.” The facility’s investigation concluded the LPN’s actions constituted verbal and physical abuse and led to disciplinary action and termination, but the administrator did not submit the required report of this substantiated abuse and employment action to the state licensing authority as mandated by Michigan law, stating that although the form was completed, it was never faxed.
A resident with multiple pressure ulcers, hemiplegia, and significant skin integrity impairment had physician orders and a care plan for daily wound care to the right elbow, right plantar foot, and heel, continuous use of a soft pillow boot on the right arm, pressure-reducing boots to both feet, and regular turning and repositioning. Surveyors observed the resident in bed without the ordered pressure-reducing boots, with feet resting directly on the mattress, and later found the right elbow wound open to air with no dressing present. Staff interviews confirmed that the resident was supposed to have these pressure-relief devices in place at all times and that the resident tolerated them, while an LPN acknowledged that CNAs often failed to report when dressings were removed or dislodged, leading to missed reapplication. These findings show the facility did not consistently implement the resident’s care plan and wound care orders.
A resident with dysphagia and malnutrition, dependent on tube feeding, was repeatedly observed receiving Jevity 1.5 at 80 mL/hr while lying flat or with the head of bed below the ordered 30-degree elevation. Open Jevity containers, including one from the prior day and another undated, were left partially full on the tray table, and the feeding bag in use was not labeled or dated over multiple observations. An LPN acknowledged the resident was positioned "way too flat" and that enteral formulas should be dated and discarded appropriately, but no further assessment was performed. These actions and omissions conflicted with the resident’s orders, care plan, and the facility’s enteral feeding policy requiring semi-Fowler’s positioning and proper formula dating.
A resident with a history of elopement risk and severe psychiatric conditions exited the facility unnoticed, despite having a Wanderguard and being care planned for elopement risk. Staff failed to respond appropriately to repeated exit door alarms, did not conduct a code search when the resident was missing, and did not accurately document the resident's elopement risk, resulting in the resident being found outside the facility by an off-duty staff member.
Surveyors observed multiple failures in food service safety, including unclean utensils and pans, improper cooling and storage of food, incorrect storage of ice and ice scoops, a faulty refrigeration seal, plumbing issues in the chemical closet, and excessive sanitizer concentrations. These actions and inactions did not meet professional standards and FDA Food Code requirements.
A resident with hypertension received Lotrel outside of physician-ordered blood pressure parameters on multiple occasions. Despite a pharmacy recommendation to remind staff about proper administration, the DON did not recall the recommendation and did not provide follow-up education to nursing staff. Facility policy requiring adherence to physician orders for medication administration was not followed.
The facility did not consistently honor residents' documented food preferences and allergies, resulting in multiple residents being served unwanted or allergenic foods. Several residents expressed frustration and sadness over receiving items they disliked or were allergic to, and staff interviews revealed a lack of awareness and adherence to dietary requirements. One resident with a known allergy to pickles and cucumbers was served potato salad containing pickles, leading to an allergic reaction and the need for medication.
A resident with a history of stroke and impaired use of her dominant arm was not provided with the built up utensils specified in her care plan and physician's orders. Despite clear documentation and staff acknowledgment of the need for adaptive equipment, the resident was repeatedly served regular silverware, resulting in observable difficulty eating and handling utensils.
Surveyors observed unsanitary conditions in common and spa areas, including food debris on furniture, dried bowel movement on commodes, and improper storage of clean linens and hygiene products. Multiple exit doors had gaps and faulty weatherstripping, allowing light, air, and potential pest entry. Staff interviews confirmed these practices did not follow facility protocols for cleanliness and storage.
A resident was left alone in her room with multiple medications provided by an LPN, without a completed self-administration assessment or physician order as required by facility policy. The DON confirmed that the necessary evaluation had not been performed, and the medications were removed after the oversight was discovered.
A resident with a documented DNR order was given CPR by an LPN after becoming unresponsive, as staff were unable to quickly verify the resident's code status. Approximately 45 seconds of compressions were performed before the DNR was confirmed and CPR was stopped. The incident highlighted that code status information was not readily accessible to staff during emergencies, leading to the failure to honor the resident's advance directive.
A resident was inaccurately assessed as having schizophrenia on multiple MDS assessments, despite no supporting diagnosis, behaviors, or treatment orders in their medical record. Staff interviews confirmed the error, and the resident's actual diagnoses included depression and dementia without psychotic features.
Staff did not follow Enhanced Barrier Precautions for a resident with an abdominal feeding tube and moderate cognitive impairment. During high-contact care activities, two CNAs wore gloves but failed to wear gowns as required, despite clear signage and facility policy. One CNA admitted to forgetting the precautions and not always noticing the posted signage, and the DON confirmed the resident was on EBP requiring both gowns and gloves.
The facility did not have a full-time Registered Dietitian or Certified Dietary Manager overseeing food and nutrition services. The Dietary Manager had not completed the required certification within the allowed timeframe and believed he had more time to do so. The dietitian only visited two days per week, and staff records confirmed the absence of a full-time qualified dietary professional.
A resident with complex medical and psychological conditions experienced inappropriate interactions with staff due to inadequate training in handling severe behavioral and mental health concerns. An LPN used inappropriate language, and staff lacked specific training for managing such behaviors, leading to unmet care needs and inappropriate interactions.
A resident with a complex medical and behavioral history was involuntarily secluded after becoming agitated, leading to a physical altercation with staff. The staff did not effectively manage the situation, lacking training specific to the resident's needs. The facility's training on handling mental health crises and performing physical restraints was found to be insufficient.
The facility's infection control surveillance was found deficient due to inaccurate and incomplete data collection. The IP failed to provide a current list of residents on antibiotics, and the infection control report did not accurately reflect the status of several residents receiving treatment. The DON confirmed that daily discussions on infections and antibiotics were not properly documented in the report, leading to ongoing non-compliance.
The facility failed to follow professional standards for medication administration and documentation. An RN administered medications to two residents simultaneously without confirming their identities or the medications, and documented medications for three residents incorrectly. The RN did not follow proper procedures for verifying and documenting medications, and admitted to not knowing the facility's policy. The DON confirmed that the facility's procedures were not followed, posing a risk of medication errors.
A resident with a history of breast cancer and reconstructive surgery felt humiliated and embarrassed due to missing bras, which were essential for her self-esteem. Staffing issues in the laundry department led to delays in returning personal items, and the nursing staff failed to address the resident's concerns promptly, impacting her dignity and quality of life.
Widespread Roof Leaks, Water Damage, and Resident Fall Due to Unsafe Environment
Penalty
Summary
The facility failed to maintain the roof and interior ceilings in a safe, functional, and sanitary condition, resulting in widespread leaks and water damage throughout resident care areas. Observations on multiple halls revealed discolored, brown, and black ceiling tiles, sagging tiles, bubbling and chipping wall surfaces, rusted light fixtures, and makeshift systems such as plastic tarps funneling water into buckets at the nurses’ station. The East wing medication room and spa areas showed signs of heavy moisture damage, and numerous ceiling tiles in various halls were dried out and stained, indicating ongoing and repeated water intrusion. One cognitively intact resident had lived in a room with a large orange ceiling stain near a light fixture, measuring approximately 17 by 22 inches, with raised areas suggesting buildup or deterioration. This resident reported that the ceiling had been leaking for over a year, causing the light fixture to stop working and requiring him to move his bed and eventually be transferred to another room. Facility records confirmed that he was moved from that room due to roof leaks, and resident council minutes documented resident concerns about leaks in rooms. Another resident, with chronic pain, depression, and moderate cognitive impairment, experienced a fall in his room after slipping on water that had leaked from the roof onto the floor. An incident report and staff interviews described the resident being found on the floor near his bed with water present on the floor, and the resident himself reported that the roof had been leaking into his room for quite some time. Multiple staff members, including CNAs and the former DON, reported that the roof had been leaking for months to over a year, that residents and their belongings were getting wet, that residents were frequently moved from leaking rooms, and that leaks extended into shower rooms where residents were being dripped on during showers.
Failure to Protect Residents From Verbal and Physical Abuse by Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and physical abuse by nursing staff. One cognitively intact resident with a BIMS score of 13 reported that a night-shift RN told him he did not need oxygen, said “f*** you, I hate you,” and gave him the middle finger during a late-night interaction. The resident stated this was the first time the RN had used that specific profanity toward him, but that the RN had previously told him he did not like him. The resident’s roommate, who also had a BIMS score of 13, corroborated hearing the RN and the resident arguing and hearing the RN use a curse word and say “I hate you.” Facility documentation, including the facility-reported incident and complaint forms, identified this as an allegation of verbal abuse by the RN, and the facility concluded that verbal abuse had occurred based on the resident’s report and the roommate’s confirmation. A second deficiency involved physical and verbal abuse of another resident by an LPN. This resident had chronic pain, anxiety, dementia, and a BIMS score of 9, indicating moderate cognitive impairment, and was care planned for impaired communication and potential verbal aggression related to dementia, depression, and poor impulse control. On the evening in question, the resident was pacing the hallway as was her usual pattern. According to the LPN involved, she approached the resident at another nurse’s medication cart, asked the resident to give the other nurse space, and then, after the resident turned and began swinging at her, she got behind the resident and guided her to her room with her hands around the resident’s arms. The LPN stated the resident went into her room, continued pacing, and voiced intent to leave, and that she did not yell but had a loud voice. Multiple staff witnesses provided a different account of the same event, describing escalating verbal and physical actions by the LPN toward the resident. A former CNA reported that the LPN had been rude to the resident earlier, then told the resident she was bothering the other nurse and needed to go to her room. When the resident refused, the LPN escalated, grabbed both of the resident’s wrists, forced her arms together behind her back, and held them up in a way that appeared painful while walking her down the hall. The CNA stated the resident repeatedly yelled “ouch, that hurts” and “get off of me,” and that the LPN “bashed” the resident into a utility closet door and then into the entrance area of the resident’s room before entering the room and slamming the door. The CNA reported hearing further “bashing” noises and the resident screaming “Stop, I can’t breathe,” and later observed the resident visibly shaken, crying, with disheveled hair, and reporting that the LPN had choked her and thrown her to the ground. Another LPN witness stated that the resident had been calmly standing and chatting at her med cart, which helped the resident’s anxiety, and that the resident was not being disruptive when the involved LPN approached and told the resident the nurse did not want her bothering her. According to this witness, the resident laughed, which appeared to escalate the LPN, who then loudly insisted the resident go to her room. When the resident refused and attempted to strike the LPN, the LPN grabbed the resident’s arms, “whipped” them behind her back, and walked her toward her room while the resident yelled that she was being hurt and tried to break free. This witness also described the LPN picking up the resident and slamming her into the utility closet door, then taking her toward her room, after which loud bashing noises and the resident’s yelling were heard from the room. Both this LPN and the CNA reported seeing the LPN slam the resident’s door on her twice as the resident tried to exit, while yelling at her to stay in her room, and hearing the LPN say she would “fight” the resident. Additional corroboration came from the receptionist, who encountered the resident shortly after the incident. The receptionist described the resident speed walking, crying, and saying she had just gotten into a fight. When the receptionist attempted to escort the resident back toward her room, the resident became more distressed and said she did not want to go down that hallway because she did not want another fight. The receptionist observed the resident’s hair was messed up and that she appeared very shaken, and reported that the resident said the LPN had grabbed her by the shirt and thrown her down. The administrator later confirmed that, based on witness interviews, she substantiated that the LPN had verbally and physically abused the resident. Together, these events demonstrate that the facility failed to ensure residents were free from verbal and physical abuse by staff, as required by its abuse policy and resident rights. The facility’s own investigation documents characterized the LPN’s conduct as verbal and physical abuse and noted that the LPN did not use de-escalation skills and that her frustration intensified the situation. The resident involved had known behavioral and communication needs, including dementia and a history of pacing and anxiety, and the care plan called for specific communication and de-escalation strategies such as not rushing, using simple cues, and providing verbal and physical cues to alleviate anxiety. Despite these identified needs and interventions, the LPN’s actions, as described by multiple witnesses and the resident, involved forceful physical handling, painful arm positioning, slamming into doors, door slamming to confine the resident, and threatening statements, all of which constituted abuse and a failure to follow the resident’s care plan and the facility’s abuse policy. In both cases, the residents and witnesses were considered by the administrator and social worker to be reliable historians without a known history of making false allegations. The facility’s own documentation and interviews with leadership acknowledged that verbal abuse occurred in the first case and that verbal and physical abuse occurred in the second case. These findings establish that the facility did not protect residents from all types of abuse by staff, including verbal and physical abuse, as required by regulation and by the facility’s own abuse policy, resulting in residents being subjected to abusive language and physically abusive handling by nursing staff.
Failure to Report Substantiated Staff Abuse to State Licensing Authority
Penalty
Summary
The deficiency involves the facility’s failure to follow policies and state law requiring timely reporting of staff-to-resident abuse to the appropriate state licensing authority. Resident #104, who had chronic pain, anxiety, and dementia, was involved in an incident where an LPN (LPN CC) engaged in conduct that the facility later substantiated as verbal and physical abuse. According to the facility-reported incident investigation, the resident was agitated and pacing when LPN CC instructed the resident to go to her room and stay there. The resident refused, approached the LPN, and attempted to strike her. LPN CC then placed the resident’s arms behind her back, physically assisted the resident to her room, and closed the door, during which the resident stated, “stop that hurts.” The facility’s in-depth analysis documented that the LPN did not use de-escalation skills and that her frustration intensified the situation, resulting in verbal and physical abuse. The investigation summary did not document that the facility reported LPN CC to the State Bureau of Professional Licensing, despite the substantiated abuse and the disciplinary action taken against the nurse. During interviews, the Nursing Home Administrator confirmed that she had substantiated the verbal and physical abuse and that the LPN’s employment had been terminated. When asked whether the termination and abuse had been reported to the State Bureau of Professional Licensing, the administrator initially could not recall and later confirmed that no report had been made. She stated that she had completed the reporting form but forgot to fax it, and the report was missed. This failure to report occurred despite state law (Michigan Public Health Code MCL 333.20175) requiring health facilities to report specified disciplinary actions and employment changes related to licensed health professionals within 30 days.
Failure to Implement Ordered Pressure-Relief and Wound Care Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions and physician-ordered wound care for a resident with significant skin integrity issues. The resident had chronic pain, a history of cerebral infarction with expressive aphasia, left hemiplegia, obesity, bowel incontinence, diarrhea, and moderate protein-calorie malnutrition, and was identified as having actual impairment to skin integrity. The care plan and orders included daily wound care to the right elbow, right plantar foot, and heel, as well as continuous use of a soft pillow boot on the right elbow and pressure-reducing boots to both lower extremities, along with turning and repositioning every two hours and as needed. Despite these orders and care plan interventions, surveyor observations on the same day showed the resident lying on her back in bed without the ordered pressure-reducing boots, which were instead found in a chair, and her feet resting directly on the bed without any offloading devices. Further observation during wound care revealed that when the RN removed the soft pillow from the resident’s right arm, the right elbow wound was open to air with no dressing in place, and no dislodged dressing could be found in the bed or on the floor. Interviews with staff confirmed that the resident was supposed to wear the pressure-reducing devices on the right arm and both feet at all times and that the resident tolerated these devices well. The wound care NP stated that the resident was at high risk for worsening skin breakdown and that adherence to pressure-reducing interventions was crucial. An LPN reported that CNAs were not consistently communicating when dressings became soiled or dislodged and were removed, resulting in nurses not being notified to reapply dressings. These observations and interviews demonstrate that the facility did not consistently implement the resident’s care plan interventions and wound care orders as written.
Failure to Maintain Safe Positioning and Handling of Enteral Nutrition
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate care and monitoring for a resident receiving enteral nutrition. The resident had a history of dysphagia following a cerebral infarction and moderate protein-calorie malnutrition, and was dependent on tube feeding and water flushes. Physician orders and the care plan required Jevity 1.5 at 80 mL/hr at bedtime and elevation of the head of bed to at least 30 degrees during feeding. On multiple observations, the resident was found lying flat or with the head of bed not elevated to 30 degrees while the tube feeding was running. During one observation, the assigned LPN acknowledged that the resident was “way too flat” and raised the head of bed to 45 degrees but did not further assess the resident. The facility also failed to ensure proper handling and labeling of enteral feeding formula. Surveyors observed two opened bottles of Jevity on the resident’s tray table, one dated from the previous day and one not dated, both partially full. The running formula bag was not labeled or dated to indicate when the formula was opened or when the feeding was started, and this lack of labeling persisted across several observations on consecutive days. The LPN caring for the resident stated that the open Jevity containers should have been discarded and that nurses were supposed to date enteral feeding formulas with the date and time when opened to ensure the formula was safe and not spoiled. These practices were inconsistent with the facility’s enteral feeding policy, which required residents to be in semi-Fowler’s position (30–45 degrees) during administration and for 30 minutes to one hour after to prevent aspiration.
Failure to Prevent Elopement and Inadequate Response to Exit Door Alarm
Penalty
Summary
A deficiency occurred when a resident, identified as being at risk for elopement due to a history of attempts to leave the facility unattended, impaired safety awareness, severe depression with psychotic symptoms, and anxiety, was able to exit the facility without staff knowledge. The resident had a Wanderguard device in place and was care planned for elopement risk, including interventions such as placement and function checks of the Wanderguard, redirection, and 1:1 observation as of the date of the incident. Despite these interventions, the resident was able to leave the facility in a wheelchair and was found approximately 50 yards away on a sidewalk near a road by an off-duty staff member. Staff interviews and record reviews revealed that on the morning of the incident, multiple staff members heard the exit door alarm sounding several times but did not respond appropriately. One CNA deactivated the alarm without fully investigating the cause or ensuring all residents were accounted for, and did not call a code search when the resident's whereabouts were unknown. The DON also deactivated the alarm and returned to her office without first checking outside the building for a missing resident. The alarm system was observed to function properly, sounding when a Wanderguard was near the door, regardless of whether the door code was entered. However, staff failed to follow protocol for responding to exit alarms and did not ensure the safety of residents at risk for elopement. Documentation also showed that the resident's elopement risk assessments were not accurately completed prior to the incident, as they did not reflect the resident's ongoing verbalizations and behaviors indicating a desire to leave. Staff interviews confirmed that the resident had been expressing anger and a desire to leave the facility, but these were not properly documented in the risk assessments. The combination of inaccurate assessments, failure to respond appropriately to exit alarms, and lack of immediate action to locate the resident resulted in the resident eloping from the facility without staff knowledge.
Removal Plan
- DON and nurse assessed Resident #101 in the parking lot and returned him to the facility.
- Resident #101's responsible party was notified.
- Resident #101 was placed in dining room under supervision for breakfast and then on 15-minute checks, escalating to 1:1 supervision after further elopement attempt, until transfer to psychiatric facility.
- Resident #101's elopement risk assessment was updated, and his care plan and orders were reviewed.
- Resident #101's Wanderguard was tested for function and placement upon return to building.
- Elopement books were updated and placed at the front desk and each nurse's station.
- Housekeeping Supervisor and Maintenance Director inspected all emergency exits and completed a Wanderguard test on doors.
- Secure Care was notified to validate door function; maintenance reviewed main door for proper alarm function.
- Secure Care validated and cleared system functions.
- All residents were assessed for risk of elopement; residents determined at risk had care plans reviewed for completeness.
- Maintenance Director or Housekeeping Supervisor/designee checks and logs all exit doors for proper function; Administrator reviews logs.
- DON/designee provided education to staff regarding Elopement policy, including immediate response to door alarms, exiting building for full view, use of light source, and calling code search if no one is observed.
- Staff were educated; remainder received 1:1 education or were educated upon arrival to work before assignment.
- Ongoing staff education on Elopement Policy and procedure, including residents at risk for exit seeking and Wanderguard use.
- Missing Guest Book/Residents with Wanderguards is updated minimally weekly and with any changes by the Interdisciplinary team.
- DON/Designee reviewed all residents at risk for exit seeking and Wanderguards for elopement risk; ongoing assessment upon admission, quarterly, and with change of condition.
- Administrator reviewed the investigation performed by DON and interviewed all staff from relevant shifts.
- Administrator and QAPI committee reviewed the missing guest policy and deemed it appropriate.
- Administrator audited the elopement books for accuracy and currency.
- New employee orientation includes Elopement policy and procedure education.
- Maintenance Director/Designee checks alarmed doors as part of Preventative Maintenance; findings submitted to QAPI committee; Administrator reviews logs.
- Code search drills were held on all shifts; ongoing process of code search drills.
- Medical Director was made aware of the elopement.
- Incident reviewed in ad hoc and monthly QAPI meetings; root cause analysis performed; decision to add light source to reception desk for search.
- Continued education on elopement policy and response to alarms, complete visualization, and calling code search; drills to ensure proper response and reduce alarm fatigue.
- All staff completed education prior to next shift worked.
Deficient Food Service Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain professional standards for food service safety, as evidenced by multiple observations of unclean kitchen equipment and improper food handling. During a kitchen tour, clean utensil bins were found to contain utensils with dried food debris, and clean pots and pans had stuck-on food and faded date stickers that should have been removed during washing. Large sheet pans stored under a preparation table were observed with encrusted grease, and the Dietary Manager acknowledged that staff often rely solely on the dish machine rather than scrubbing by hand. Additionally, the seal gasket on a refrigeration unit was not properly attached, compromising its ability to maintain a good seal. Improper storage and handling of ice and ice scoops were also noted. An ice chest used for water pass was found full of ice with no drainage for melted water, and ice scoops in two pantries were stored right side up in their holders, contrary to best practices for air drying and contamination prevention. The facility did not regularly log cooling for food saved from service, and sausage patties from breakfast were left in a tightly covered container on a preparation table before being moved to a cooler, where their temperature was found to be 88°F, indicating improper cooling procedures. Further deficiencies included a kitchen chemical closet with a four-way splitter on the faucet, causing constant back pressure on the internal vacuum breaker, and two spray bottles of quaternary ammonium sanitizer in the dish machine area with concentrations around 500 ppm. These findings demonstrate a lack of adherence to FDA Food Code requirements for equipment cleanliness, food cooling, utensil storage, plumbing maintenance, and chemical sanitizer use.
Failure to Adhere to Medication Administration Parameters for Antihypertensive
Penalty
Summary
Nursing staff failed to administer medication in accordance with physician orders for a resident with hypertension. The resident had a physician order for Lotrel, an antihypertensive medication, to be held if the systolic blood pressure (SBP) was less than 110 or heart rate was less than 60. Despite this, review of the Medication Administration Record showed that Lotrel was administered on multiple occasions when the resident's SBP was below the ordered threshold. Documentation indicated that an LPN was responsible for administering the medication on most of these occasions. A pharmacy consultation report identified the issue and recommended that staff be reminded of the importance of adhering to medication administration parameters. However, the DON, who signed the pharmacy recommendation, reported not recalling the recommendation and confirmed that no follow-up education or action was taken to ensure staff compliance with the ordered parameters. The facility's own policy requires medications to be administered according to physician orders, but this was not followed in this case.
Failure to Honor Resident Food Preferences and Allergies
Penalty
Summary
The facility failed to consistently honor residents' food and drink preferences, allergies, and intolerances as documented on their meal tickets and care plans. Multiple residents were observed being served food items they had specifically indicated as dislikes, such as sausage, eggs, black pepper, carrots, zucchini, and lima beans, despite these preferences being clearly listed. Residents expressed frustration, sadness, and anger over receiving unwanted food and drink items, and some reported that this was a common occurrence. In several cases, residents left the unwanted food uneaten, and one resident noted that she did not receive the correct number of coffee creamers as requested. In addition to disregarding preferences, the facility also failed to prevent exposure to known food allergens. One resident with documented allergies to cucumbers and pickles was served potato salad containing pickles, which resulted in him experiencing mouth itching and requiring antihistamine and anti-nausea medication. The resident expressed ongoing fear and vigilance regarding his meals due to this incident. Review of his records showed that his allergies were documented in multiple places, including his meal ticket and medical record, but this information was not effectively communicated to or recognized by all staff involved in meal delivery. Interviews with dietary staff and CNAs revealed a lack of awareness and adherence to residents' documented food preferences and allergies. The dietary manager confirmed that food items were available to meet residents' preferences but were not provided as required. Staff also failed to cross-reference ingredient lists with residents' allergies, leading to the serving of allergenic foods. The facility's own policy required that food preferences be identified and honored on tray tickets, but this was not consistently implemented.
Failure to Provide Adaptive Dining Equipment for Resident with Stroke History
Penalty
Summary
A resident with a history of stroke and impaired use of her dominant right arm was repeatedly not provided with the adaptive dining equipment specified in her care plan and physician's orders. Despite clear documentation on her meal tickets and in her care plan indicating the need for built up utensils, she was served regular silverware at multiple meals. Observations showed the resident struggling to handle standard utensils, resulting in awkward and insecure grips, slow eating, and multiple attempts to pick up food. The resident herself reported difficulty using regular utensils and stated that built up utensils would make eating easier. Interviews with staff, including the Dietary Manager, confirmed that the resident was supposed to receive built up utensils with all meals as ordered. The facility's policy also required culinary staff to provide adaptive equipment for residents who would benefit from their use. Despite these requirements, the resident was not provided with the necessary adaptive utensils during the observed meals, leading to ongoing difficulty with eating.
Failure to Maintain Sanitary and Safe Environment in Common and Spa Areas
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During multiple tours of common areas, including the East Day room, East Hall Spa, and various shower rooms, surveyors observed accumulations of food crumbs, paper trash, and debris under and around seat cushions, as well as on furniture. In spa and shower areas, dried bowel movement was found on commodes, and there was an accumulation of dirt and debris behind toilets. Clean linens such as wash cloths and towels were improperly stored on shower chairs and paper towel holders, rather than in designated cabinets, and personal hygiene products were stored alongside cleaning disinfectants. Staff interviews confirmed that these practices were not in accordance with facility protocols, as these areas and items should be cleaned and stored properly to maintain sanitation. Additionally, during a facility-wide inspection, several exit doors were found to have gaps and spaces between the doors, frames, and weatherstripping, allowing visible light, air, and potential pest entry. These deficiencies were observed at multiple exit points, including hall doors and the dining room exit. The combination of unsanitary conditions, improper storage of linens and hygiene products, and compromised building integrity contributed to an environment that was not safe, sanitary, or comfortable for residents, staff, or visitors.
Failure to Assess and Authorize Resident for Medication Self-Administration
Penalty
Summary
A resident was observed alone in her room with eight pills in a disposable medication cup placed next to her meal tray. The medications had been provided by an LPN prior to breakfast, but the resident had not yet taken them, and no staff were present in the room or nearby. The LPN later confirmed she had given the medications to the resident and was unaware they had been left unattended. Upon discovering the situation, the LPN removed the medication cup containing buspirone, duloxetine, ferrous gluconate, furosemide, lisinopril, metformin, metoprolol, and Tylenol from the resident's room. Review of the resident's record revealed that no medication self-administration assessment had been completed, and there was no physician order authorizing self-administration. The facility's policy requires a self-administration evaluation and physician authorization before a resident is permitted to self-administer medications. The resident was cognitively intact according to a recent mental status score, but the required assessment and documentation were not in place, resulting in the resident being left alone with medications contrary to facility policy.
DNR Order Not Honored Due to Delayed Code Status Verification
Penalty
Summary
A deficiency occurred when a resident with a documented Do Not Resuscitate (DNR) order received cardiopulmonary resuscitation (CPR) from facility staff. The resident had a clearly documented DNR order, signed by both the resident and the attending physician, indicating that no resuscitation should be attempted in the event of cardiac or respiratory arrest. On the day of the incident, the resident became unresponsive and staff could not detect a pulse after a transfer using a hoyer lift. A Licensed Practical Nurse (LPN) responded to calls for help and, unable to immediately confirm the resident's code status, initiated CPR. The LPN reported that she began compressions because staff were unable to quickly provide the resident's code status, and she acted as she would in a situation where code status was unknown. Approximately 45 seconds of compressions were performed before other staff confirmed the DNR status, at which point CPR was stopped. The resident subsequently regained a pulse and began breathing again. Interviews with staff revealed that the process for verifying code status was not efficient, as the information was only available in the computer and not readily accessible during emergencies. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that CPR was performed on a resident with a DNR order and that no incident report or immediate follow-up education was completed after the event. The facility's policy required staff to validate code status before initiating CPR, but this was not followed due to delays in accessing the information.
Inaccurate MDS Assessment Due to Erroneous Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a resident received an accurate clinical assessment reflective of their actual status at the time of assessment. Specifically, the Minimum Data Set (MDS) assessments for the resident on two separate occasions documented an active medical diagnosis of schizophrenia. However, a review of the resident's electronic health record showed no diagnosis of schizophrenia, no documented behaviors, and no treatment orders related to schizophrenia. The resident's PASARR evaluation also indicated no mental illness, and behavioral care notes described diagnoses of major depressive disorder and dementia without behavioral or psychotic disturbances. Interviews with facility staff confirmed that the resident did not have any orders for psychotropic medications and did not exhibit behaviors indicative of schizophrenia. The MDS-Registered Nurse acknowledged that the schizophrenia diagnosis was entered in error on multiple MDS assessments. This inaccurate documentation resulted in the resident's clinical status being misrepresented in official records.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with an abdominal feeding tube and moderate cognitive impairment. During high-contact care activities, including transferring the resident from a wheelchair to bed, assisting with positioning, and checking the resident's incontinence brief, two Certified Nursing Assistants (CNAs) wore gloves but did not wear gowns as required by the facility's EBP policy. Signage on the resident's door clearly indicated that both gloves and gowns were required for high-contact care activities such as transferring and changing briefs. The CNAs involved acknowledged that they had received training on EBP but one CNA admitted to forgetting the resident was on these precautions and sometimes not noticing the posted signage. The Director of Nursing/Infection Preventionist confirmed that the resident was on EBP and that staff were required to wear both gowns and gloves during high-contact care. Review of the facility's policy and physician orders confirmed the requirement for EBP, including the use of gowns and gloves for specified care activities.
Lack of Qualified Dietary Oversight
Penalty
Summary
The facility failed to employ a full-time Registered Dietitian or a Certified Dietary Manager to oversee kitchen and clinical nutritional services. During a kitchen tour, it was observed that the current Dietary Manager had not yet completed the Certified Dietary Manager certification, despite being in the position for over a year. The Dietary Manager believed he was allowed the full duration of the certification course, which is 18 months, rather than the one year permitted upon hire. Additionally, the dietitian only visits the facility two days a week, and a review of staff records confirmed there was no full-time Certified Dietary Manager or full-time Dietitian on staff.
Inadequate Staff Training for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that staff members possessed the necessary competencies and skills to meet the behavioral health needs of residents, particularly in the case of a resident with complex medical and psychological conditions. This resident, a female with diagnoses including spina bifida, chiari syndrome, anxiety, depression, and mood disorders, experienced inappropriate interactions with staff. An incident was reported where an LPN used inappropriate language towards the resident, telling her to "get your ass in your room," which was witnessed by other staff members. The resident expressed dislike for the LPN and another CNA, indicating a strained relationship. Further investigation revealed that the staff lacked training specific to handling residents with severe behavioral and mental health concerns. Interviews with various staff members, including CNAs and LPNs, highlighted a gap in training for dealing with residents who have mental health issues beyond dementia and Alzheimer's. The staff reported feeling unequipped to manage the resident's behaviors, and there was a lack of documented interventions in the resident's care plan to address such situations. The facility's social worker, who was temporarily filling in, also noted that staff did not have a deep understanding of the residents' triggers and effective interventions. The Director of Nursing acknowledged that the staff did not implement person-centered behavioral interventions as outlined in the care plan. The care plan suggested moving the resident to a quiet place to calm down, but the staff's actions of forcing the resident into her room were not part of the care plan. The facility's administrator recognized the challenges faced by the staff in dealing with a younger population with mental health concerns and noted that previous incidents might have influenced staff responses. Despite some training efforts, the facility's staff were not adequately prepared to handle the specific behavioral health needs of the resident, leading to unmet care needs and inappropriate staff-resident interactions.
Failure to Prevent Involuntary Seclusion of Resident with Complex Needs
Penalty
Summary
The facility failed to prevent involuntary seclusion of a resident, identified as Resident #102, who has a complex medical history including spina bifida, chiari syndrome, anxiety, depression, and other conditions. The resident's care plan highlighted past trauma and specific triggers, such as being alone with males and loud noises, which could lead to increased anxiety and agitation. Despite these known triggers, the staff did not effectively manage the resident's behavior, leading to an incident where the resident became agitated and was involved in a physical altercation with staff. On the day of the incident, Resident #102 became frustrated with another resident and a visitor, leading to a situation where staff attempted to escort her to her room. The resident resisted, resulting in a physical struggle where she scratched and attempted to bite staff members. The staff involved did not attempt to redirect the resident or implement other interventions from her care plan, and instead focused on physically moving her to her room, which escalated the situation. Interviews with staff revealed a lack of training specific to handling residents with severe behavioral and mental health issues, contributing to the inadequate response. The facility's training on abuse and neglect was found to be insufficient, with a significant number of staff not having completed the required education. Additionally, staff reported not receiving training on handling mental health crises or performing physical restraints, which are not used by the facility. The lack of appropriate training and intervention strategies for dealing with residents with complex behavioral needs was a significant factor in the failure to prevent the involuntary seclusion of Resident #102.
Inaccurate Infection Control Surveillance in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control surveillance plan, as evidenced by the lack of accurate and timely data collection and interpretation for residents with infections. The Infection Preventionist (IP) reported using a computer-based program for infection control surveillance but was unable to provide a current list of residents on antibiotics or confirm their inclusion in the program. The IP acknowledged that there were eight residents with infections but had not yet collected all necessary information. The infection control report was found to be inaccurate, as it did not reflect the current status of several residents, including those who were still receiving antibiotic treatment. Specific deficiencies were noted in the cases of four residents. One resident's antibiotic treatment was inaccurately reported as completed, while another resident's ongoing treatment was not included in the report. Additionally, two residents with infections were omitted from the surveillance report entirely. The Director of Nursing (DON) confirmed that infections and antibiotics are discussed daily in morning meetings and should have been accurately reflected in the infection control report. The Nursing Home Administrator was informed of the ongoing non-compliance, which precluded acceptance of past compliance efforts.
Failure to Follow Medication Administration and Documentation Standards
Penalty
Summary
The facility failed to follow professional standards of practice for medication administration and documentation for six residents. During an observation, a Registered Nurse (RN) was seen administering medications to two residents simultaneously without confirming their identities or the medications. The medication cups were not labeled, and the RN did not follow the proper procedure for documenting medication administration. Additionally, the RN documented medications for three residents that were either refused, already administered, or given by another nurse, which is against the facility's policy. Further observations revealed that the RN did not compare medications with physician orders or check off medications as they were pulled from the cart. The RN admitted to not knowing the facility's policy on medication documentation and did not see an issue with administering medications to two residents at the same time. The Director of Nursing (DON) confirmed that the facility's procedure requires nurses to verify medications with orders, identify residents before administration, and document immediately after administration. The DON also stated that preparing medications for multiple residents simultaneously is not allowed and poses a risk of medication errors.
Failure to Promote Resident Dignity Due to Laundry Issues
Penalty
Summary
The facility failed to provide an environment that promoted resident dignity for a resident with a history of breast cancer and reconstructive surgery. The resident reported feeling self-conscious about the difference in the size of her breasts and expressed a preference for wearing a bra to make them appear more equal. However, the resident's bras had been going missing, and although the facility replaced them, the process took time, leaving the resident without a bra on multiple occasions. This situation caused the resident to feel humiliated and embarrassed, impacting her sense of dignity and self-worth. Interviews with staff revealed that the facility's laundry department had been experiencing staffing issues, leading to delays and problems in returning residents' personal items, including the resident's bras. The Certified Nursing Assistant (CNA) and Housekeeping Manager (HKM) both acknowledged the challenges in managing the laundry due to recent staff turnover and the need to label new residents' clothing promptly. Observations of the laundry area confirmed that there were significant amounts of personal laundry in various stages of processing, further indicating the backlog and inefficiencies in the system. The Director of Nursing (DON) confirmed that the laundry department had been understaffed due to retirements and resignations, which contributed to the delays in returning personal items to residents. The DON also noted that the nursing staff had not addressed the resident's concern on the day it occurred, and she was unaware of the situation until it was reported to her. This lack of timely response and communication further exacerbated the resident's distress and feelings of indignity.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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