The Lodge At Taylor
Inspection history, citations, penalties and survey trends for this long-term care facility in Taylor, Michigan.
- Location
- 22950 Northline Rd, Taylor, Michigan 48180
- CMS Provider Number
- 235541
- Inspections on file
- 37
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at The Lodge At Taylor during CMS and state inspections, most recent first.
Four out of five shower gurneys were found missing required safety pins to secure side rails, with no evidence of routine safety checks or requests for replacement. Staff competency records also lacked education on proper gurney use, despite facility policy requiring safe maintenance of patient care equipment.
A resident with severe cognitive impairment and physical disabilities was found unable to access their call light, which was observed on the floor and out of reach during meal assistance. Staff confirmed the resident could use the call button, and facility policy requires call lights to be accessible at all times. The care plan for this resident included encouraging use of the call light, but this intervention was not followed.
A resident with severe cognitive impairment and multiple health conditions received a wound patch on the right arm without a physician's order or proper documentation. An LPN and the DON confirmed that the wound care was not authorized by a physician and was not documented in the medical record, contrary to facility policy requiring physician-directed wound treatments.
A resident with severe cognitive impairment and a history of impulsive behaviors experienced multiple falls resulting in injuries and hospital visits due to the facility's failure to consistently update and implement effective fall prevention interventions. Despite repeated incidents, care plans were not revised after several falls, and staff did not provide adequate supervision or targeted interventions, particularly during nighttime hours.
The facility failed to consistently provide water to residents, leading to repeated grievances at Resident Council Meetings. Observations showed residents without water at their bedsides, and interviews revealed staff assumptions and lack of resolution. Despite in-services in October, the issue persisted, violating the facility's hydration policy.
The facility failed to maintain over-bed tables in seven resident rooms, with tables exhibiting missing edging, peeling veneer, and exposed particle board, making them difficult to clean. The Maintenance Director relies on staff to report such issues and acknowledged the need for replacement upon inspection.
The facility failed to review and submit PASARR forms for two residents, potentially impacting their mental health care. One resident was admitted with schizophrenia and anoxic brain damage, but the PASARR forms incorrectly indicated a dementia exemption. Another resident with psychosis and metabolic encephalopathy had no PASARR assessment completed. The facility's policy requires coordination with the PASARR program, which was not followed.
A resident with end-stage renal failure and osteomyelitis did not receive prescribed intravenous antibiotics during dialysis on multiple occasions. The facility failed to notify the physician of these missed doses, as confirmed by interviews with the Unit Manager, DON, and nursing staff. The facility's medication administration policy was not followed.
A resident with morbid obesity, type two diabetes, and end-stage renal failure was found to have inadequate foot care, with long, jagged, discolored toenails and debris between toes. Despite the resident's request for podiatry services, the facility failed to register or provide these services, and care plans lacked specific interventions for foot care. Interviews with facility staff confirmed the oversight in providing necessary podiatry services.
A facility failed to communicate effectively with a dialysis provider, resulting in a resident missing seven doses of prescribed antibiotics. The resident, with end-stage renal failure and osteomyelitis, was supposed to receive Cefepime and Vancomycin intravenously after hemodialysis. The DON confirmed the missed doses and identified a lack of communication between nursing staff and the dialysis provider, contrary to facility policy.
A resident with type two diabetes and impaired cognition received medication from an LPN who placed syringes directly on a cluttered bedside table without a barrier, violating facility policy. The DON confirmed this practice increases contamination risk.
A resident with cerebral palsy, epilepsy, and dementia was unable to receive timely assistance due to a malfunctioning bathroom call light. The resident, requiring substantial assistance with toileting, had to self-transfer, risking falls. The call light indicator was not functioning properly, and the Maintenance Director was unaware of the issue, as staff did not report it through the electronic repair order system.
A facility failed to perform proper hand hygiene during wound care for a resident with an open cancer lesion. An LPN did not wash hands before or after removing soiled dressings, relying instead on double gloving. The DON confirmed that hand hygiene should occur before and after wound care, and the facility's policy states gloves do not replace hand hygiene.
A resident with a history of cerebral infarction and hemiplegia was not included on the podiatrist list, leading to overgrown toenails and dissatisfaction with foot care. The resident had to arrange an outside appointment for nail trimming. The EHR showed no podiatry consults since admission, and the facility's nail care policy was not followed.
A resident with anoxic brain injury and a feeding tube did not receive tube feeding as per physician's orders, resulting in insufficient nutrition. The feeding pump was found alarming, and the feeding bottle was hung at the wrong time, leading to a shortfall of 300 ml in the prescribed amount. The DON and an LPN could not determine the duration of the feeding hold or the total amount infused, indicating a failure to follow the facility's Feeding Tube policy.
A resident with a tracheostomy did not receive the prescribed humidified oxygen due to malfunctioning equipment. The trach collar tubing was connected to a compressor set at 0% humidification, and the water bottle was leaking, causing water to accumulate in a wash basin. The resident, who was non-verbal and cognitively impaired, was not in distress. The facility's policy for tracheostomy care was not followed, as the staff failed to notify the Respiratory Therapist about the issue immediately.
A resident who underwent surgery to improve hand function did not receive the ordered Occupational Therapy (OT) sessions in a timely manner, as the facility failed to provide the required 3-5 sessions per week. The resident received only one session per week for two consecutive weeks, leading to dissatisfaction and the decision to seek therapy elsewhere. Interviews with staff confirmed the oversight, and the facility's policy mandates adherence to therapy orders.
A resident with Type 2 Diabetes and End Stage Renal Disease was found unresponsive with a blood glucose level of 35. Despite physician orders to administer glucose or glucagon for low blood sugar, the facility did not administer glucagon before EMS arrived. The resident had received insulin earlier, and no glucagon was given, leading to hospitalization and subsequent death.
A facility failed to provide accurate resident documents during an emergency hospital transfer. A resident with cognitive impairment and multiple diagnoses was transferred without the correct paperwork, as confirmed by staff interviews. The error was discovered when the hospital reported receiving incorrect information.
The facility failed to immediately report an allegation of sexual abuse involving two residents, both with no cognitive impairment. An incident where one resident was reportedly touched inappropriately by another was not reported to the State Agency until several days later, contrary to the facility's policy requiring immediate reporting. The Nursing Home Administrator did not initially consider the incident an allegation of abuse.
A resident at very high risk for pressure ulcers experienced a significant worsening of an existing stage 4 pressure ulcer due to the facility's failure to follow hospital discharge instructions for wound care. The wound care nurse did not document all dressing changes, and necessary dressing changes after bowel movements were not consistently performed. The resident's condition deteriorated, leading to septic shock and death.
The facility failed to notify the physician of abnormally elevated blood sugar levels for a resident with diabetes mellitus, despite specific orders to do so. The resident's blood sugar values were recorded as 459 and 436, but the physician was not informed, resulting in a deficiency identified during the survey.
The facility failed to ensure a physician's assessment accurately reflected a resident's current diabetes status, resulting in potential delays in appropriate medical treatments. Despite frequent high blood sugar readings, the physician's notes were repetitive and did not reflect updated assessments or adjustments in care. Interviews with staff revealed concerns about the lack of updated evaluations and adherence to the facility's policy on physician visits.
Failure to Maintain Shower Gurney Safety Equipment
Penalty
Summary
The facility failed to ensure the safe maintenance of shower gurneys, as four out of five gurneys observed were missing the required safety pins to secure the side rails. Specifically, one gurney in Hall C and two in Hall B were missing all safety pins, while a gurney in Hall E was missing two out of four pins. Maintenance logs showed no evidence of routine safety assessments for the shower gurneys, and there were no documented requests to replace the missing safety pins. Additionally, review of Certified Nursing Assistant competency forms revealed no education provided regarding the use of shower gurneys. The facility's policy requires all mechanical, electrical, and patient care equipment to be maintained in safe operating condition.
Call Light Accessibility Deficiency
Penalty
Summary
A deficiency occurred when a resident's call button was found on the floor at the head of the bed, out of the resident's reach, while the resident was awake and receiving breakfast assistance from a staff member. The resident had the capacity to use the call button, as confirmed by an LPN, but was unable to access it due to its placement. The staff member assisting with the meal did not ensure the call button was within reach during or after the assistance. The facility's policy requires that call lights be accessible to residents at all times, and the care plan for this resident specifically included encouraging the use of the call light for assistance. The resident involved had a history of atrial fibrillation, morbid obesity, and hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side, but no impairment of the upper extremities was documented. The care plan also identified the resident as being at risk for falls and injury, with interventions including the use of the call light for assistance. Despite these documented needs and interventions, the call light was not accessible, and staff confirmed this during interviews. The Director of Nursing also acknowledged that call lights should be within reach for all residents.
Wound Care Provided Without Physician Order or Documentation
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including atrial fibrillation, morbid obesity, and hemiplegia, was found with a wound patch on the right arm that lacked a corresponding physician's order and proper documentation. During observation, the wound patch was noted to be dated several days prior, and review of the electronic health record confirmed there was no physician's order or nursing note regarding the application of the patch. The resident's care plan had been updated to reflect risks and history of impaired skin integrity, but the specific wound care provided was not documented as required. Interviews with facility staff, including an LPN and the DON, confirmed that the wound patch was applied without a physician's order and that the physician had not been notified about the wound or the treatment provided. The DON acknowledged that all treatments should be documented and that the physician should have directed the wound care. Review of facility policy further indicated that physician authorization is required for wound treatments, but this protocol was not followed in this instance. No additional documentation or information was provided by the facility at the time of the survey.
Failure to Implement Adequate Fall Prevention Interventions
Penalty
Summary
The facility failed to implement adequate interventions and supervision to prevent multiple falls for a resident with severe cognitive impairment and a history of impulsive behaviors. The resident, who was non-interviewable due to cognitive impairment and had diagnoses including metabolic encephalopathy, seizure disorder, muscle weakness, bipolar disorder, and impulse disorder, experienced numerous falls resulting in injuries and hospital visits. Observations showed the resident attempting to self-propel in a wheelchair and resist redirection from staff, while interviews with the roommate confirmed frequent nighttime activity and falls. Review of the resident's care plan and medical records revealed repeated falls, some resulting in significant injuries such as lacerations requiring stitches and multiple hospital transfers. Despite these incidents, there was a lack of consistent and timely updates to the fall care plan following several falls. The care plan included interventions such as keeping the resident in common areas when awake, providing structured activities, ensuring a hazard-free room, using a mat next to the bed, and a low bed, but these interventions were not consistently revised or augmented after repeated falls. Staff interviews indicated a lack of interventions specifically targeted for nighttime, when many of the falls occurred. The Unit Manager acknowledged the absence of nighttime activities or interventions and suggested that such measures might have helped reduce the number of falls. Additionally, there was no documented follow-up on recommendations for additional safety equipment, such as bed bolsters, and the facility's fall prevention policy requiring assessment and care plan revision was not consistently followed.
Inconsistent Water Pass Leads to Resident Grievances
Penalty
Summary
The facility failed to consistently provide water to residents, as evidenced by repeated grievances reported at ten consecutive monthly Resident Council Meetings. Observations on specific dates revealed that residents were without water or water cups at their bedsides, and some residents expressed frustration over the inconsistency of water delivery. One resident, who was cognitively impaired, was unable to confirm if water had been available, while another resident with intact cognition reported that the issue had been raised multiple times without resolution. The facility's records showed that the concern of inconsistent water pass was documented in Resident Council Meeting minutes from February to November, with no effective resolution implemented. Interviews with staff, including a CNA and the Nursing Home Administrator (NHA), revealed a lack of consistent action to address the water pass issue. The CNA assumed that the previous shift had completed the water pass, while the NHA acknowledged the ongoing concerns but could not explain why no resolutions had been implemented prior to October. The Director of Nursing (DON) confirmed that some residents still did not receive water even after staff in-services were conducted in October. The facility's policy on resident hydration, which mandates daily and routine provision of fluids, was not adhered to, leading to the deficiency.
Failure to Maintain Over-Bed Tables in Resident Rooms
Penalty
Summary
The facility failed to maintain the over-bed tables in seven resident rooms, specifically rooms B4, C2, E4, G2, I11, I12, and J9. During an observation, it was noted that these tables had missing edging, peeling surface veneer, and rough, exposed particle board, making them no longer smooth and easily cleanable. This deficiency was identified during a survey conducted between 2:00 pm and 2:30 pm. In an interview, the Maintenance Director stated that he relies on staff to inform him when a table needs replacement. Upon being shown the table in room C2, which had a top surface lifted away from the particle board, he acknowledged that it was water warped and needed replacement.
Failure to Review and Submit PASARR Forms
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Annual Resident Review (PASARR) forms were properly reviewed, revised, and submitted to the local state agency for two residents, resulting in the potential for these residents not to receive appropriate care and services for their mental health needs. Resident R86 was admitted with diagnoses including paranoid schizophrenia and anoxic brain damage, and the PASARR forms indicated a dementia exemption, which was not supported by the hospital records. The social worker admitted to confusion regarding the dementia exemption and acknowledged that a Level II evaluation request was not submitted. Resident R44 was admitted with unspecified psychosis and metabolic encephalopathy, and was prescribed Risperdal for paranoia. However, there was no PASARR assessment completed upon admission, and the social worker acknowledged that the assessment was missed. The facility's policy requires coordination with the PASARR program to ensure appropriate care for individuals with mental disorders or intellectual disabilities, but this was not adhered to in these cases.
Failure to Administer Antibiotics and Notify Physician
Penalty
Summary
The facility failed to administer medications as ordered and did not notify the physician of missed doses for a resident with end-stage renal failure and osteomyelitis. The resident was supposed to receive intravenous antibiotics, Cefepime and Vancomycin, on specific days after hemodialysis. However, the Medication Administration Record showed that Vancomycin was not administered on four occasions, and Cefepime was missed on three occasions. There was no documentation indicating that the physician was informed of these missed doses. Interviews with the Unit Manager, Director of Nursing, and nursing staff revealed a lack of awareness and communication regarding the missed doses. The Director of Nursing confirmed the missed doses and stated that the antibiotics should have been administered during dialysis. The nursing staff did not inform the physician about the missed doses until several days later. The facility's policy on medication administration requires that medications be administered as ordered by the physician, but this was not adhered to in this case.
Failure to Provide Adequate Foot Care for a Resident
Penalty
Summary
The facility failed to provide adequate foot care for a resident, identified as R32, who was observed to have long, jagged, thick, greenish/black toenails, white patches of dry skin, and moist debris encrusted between the toes. Despite R32's expressed desire for podiatry services due to an inability to provide nail care independently, the facility did not register or provide podiatry care for the resident. R32 was admitted with diagnoses of morbid obesity, type two diabetes, and end-stage renal failure, and exhibited dependency with most activities of daily living (ADLs). The facility's policy on nail care, dated August 2024, requires assessments of resident nails upon admission and readmission, with routine cleaning and inspection during ADL care. However, R32's care plans did not contain specific interventions for foot care, and the staff responsible for setting up podiatry services failed to do so in a timely manner. Interviews with the Director of Nursing and the Social Worker confirmed that podiatry services should have been provided, especially given R32's comorbidities, but were not arranged. The Nursing Home Administrator acknowledged that residents should receive foot care from staff and podiatry services when needed.
Failure in Communication with Dialysis Provider Leads to Missed Antibiotic Doses
Penalty
Summary
The facility failed to effectively communicate with a dialysis provider, resulting in a resident not receiving seven doses of prescribed antibiotics. The resident, who was diagnosed with end-stage renal failure and osteomyelitis, was supposed to receive Cefepime and Vancomycin intravenously on specific days after hemodialysis. However, the Medication Administration Record indicated that Vancomycin was not administered on four occasions, and Cefepime was missed three times. The dialysis provider's communication report also showed no documentation of antibiotics being given on these days. Interviews with the Director of Nursing (DON) confirmed the missed doses and highlighted a lack of communication between the nursing staff and the dialysis provider. The facility's policy required nursing staff to report the resident's condition and treatment provisions to the dialysis provider each treatment day and to follow up if no written report was received. However, this protocol was not followed, leading to the deficiency in care for the resident.
Failure to Use Barrier During Medication Administration
Penalty
Summary
The facility failed to apply a barrier while administering medications to a resident, identified as R15, who was observed to have type two diabetes mellitus without complications and impaired cognition with a BIMS score of 10 out of 15. On the morning of 12/11/24, an LPN was seen entering R15's room with two pre-filled syringes of long-acting insulin (Glargine) and one syringe of short-acting insulin (Flasp). The LPN placed all three syringes directly on the resident's bedside table, which was cluttered with various items and debris, without using a barrier. This action was contrary to the facility's medication administration policy, which requires the use of a barrier to prevent contamination and infection. The LPN later acknowledged that the medication should not have been placed directly on the bedside table. The Director of Nursing confirmed that placing medications on surfaces without a barrier is against the facility's policy due to the risk of contamination from concealed body fluids and other unknown contaminants.
Failure to Maintain Functioning Bathroom Call Light
Penalty
Summary
The facility failed to ensure that a bathroom call light was in working order for a resident, leading to unmet care needs and potential delays in responding to emergency situations. On the specified date, the resident, who was observed in the bathroom, expressed frustration that staff did not respond to the call light. The resident, who has a history of cerebral palsy, epilepsy, and dementia, required assistance with toileting but had to self-transfer due to the lack of response. The bathroom call light indicator was activated, but the indicator outside the door was not, preventing staff from being alerted. The resident's care plan indicated a need for substantial assistance with toileting due to various health conditions, including seizures and poor balance. Despite monthly audits of call light functionality, the Maintenance Director was unaware of the malfunctioning call light in the resident's bathroom. Staff are expected to use an electronic repair order system to report issues, but this was not done in this case, resulting in the deficiency.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for a resident. On the specified date, an LPN was observed performing wound care for a resident with an open cancer lesion on the left breast. The LPN entered the resident's room and did not perform hand hygiene despite the presence of a hand sink. The LPN applied two pairs of gloves to each hand, removed the soiled dressings, and then removed all gloves without performing hand hygiene. The LPN then applied two more pairs of gloves to each hand to complete the wound care and again failed to perform hand hygiene after removing the gloves. During an interview, the LPN acknowledged that hand hygiene should have been performed when transitioning from dirty to clean dressings but did not do so because of double gloving. The Director of Nursing confirmed that hand hygiene should be performed before starting wound care, after removing soiled dressings, and after completing the treatment, and that double gloving should not replace hand hygiene. The facility's hand hygiene policy also states that gloves do not replace hand hygiene, and hand hygiene should be performed before donning and after removing gloves.
Failure to Provide Adequate Foot Care
Penalty
Summary
The facility failed to include a resident on the podiatrist list, resulting in the resident having overgrown toenails and dissatisfaction with foot care. The resident, who had a history of cerebral infarction and hemiplegia affecting the left dominant side, reported not being seen by the foot doctor and having to make an outside appointment for nail trimming. An observation confirmed that the resident's great toenails had grown past the end of the toes. The resident's Electronic Health Record (EHR) showed no podiatry consults since admission, and there was no documentation of nail care being administered. The Social Worker indicated that a complete referral to the podiatry group was not sent, and the Director of Nursing acknowledged that a referral should have been made. The facility's policy on nail care emphasized the need for regular assessment and care, which was not followed in this case.
Failure to Administer Tube Feeding Per Physician's Orders
Penalty
Summary
The facility failed to administer tube feeding in accordance with physician's orders for a resident with a feeding tube, resulting in the tube feeding being on hold for an undetermined amount of time. This led to the resident receiving less nutrition than prescribed, with the potential for insufficient nutrition, hydration, and weight loss. The resident, who had anoxic brain injury and required a feeding tube, was observed with a tube feeding pump that was alarming, indicating the feeding was on hold. The feeding bottle, containing Jevity 1.5 Cal, was hung at 9:00 PM, contrary to the physician's order to start at 12:00 PM, and only 550 ml had been infused instead of the expected 876 ml. The Director of Nursing (DON) and the resident's nurse, an LPN, were unable to determine how long the feeding had been on hold or the total amount infused over 24 hours. The facility's Feeding Tube policy requires that feeding tubes be used according to physician's orders and that the administration of enteral nutrition is consistent with these orders. However, the discrepancy in the timing and amount of feeding administered indicates a failure to adhere to these standards, as the resident was approximately 300 ml short of the prescribed amount at the time of observation.
Inadequate Tracheostomy Care Due to Equipment Malfunction
Penalty
Summary
The facility failed to provide appropriate tracheostomy care for a resident, identified as R510, who required humidified oxygen due to an anoxic brain injury. During an observation, it was noted that the trach collar tubing was connected to a compressor set at 0% humidification, contrary to the physician's orders of 5 L/28%. Additionally, the compressor's water bottle was leaking, causing water to accumulate in a plastic wash basin where the trach collection bag and some tubing were submerged. The resident, who was severely cognitively impaired and non-verbal, did not appear to be in distress at the time of observation. The Director of Nursing and a Respiratory Therapist acknowledged the incorrect humidification setting and the improper handling of the leaking equipment. The Respiratory Therapist adjusted the humidification setting and addressed the water leakage issue. The facility's policy mandates that tracheostomy care should be consistent with professional standards and the resident's care plan, which was not adhered to in this instance. The Director of Nursing noted that the staff should have notified the Respiratory Therapist immediately about the leaking equipment instead of allowing it to continue leaking.
Failure to Provide Ordered Occupational Therapy Sessions
Penalty
Summary
The facility failed to provide Occupational Therapy (OT) sessions as ordered for a resident, identified as R501, who was reviewed for physical rehabilitation. R501 had undergone surgery to lengthen tendons in the left forearm to improve hand function. Despite the physician's orders for OT sessions 3-5 times per week for 30 days, the facility's records showed that R501 received only one OT session during the week of 6/2/24 and one session during the week of 6/9/24, with no documented reasons for the missed sessions. This lack of therapy led to the resident's dissatisfaction and the decision to seek therapy outside the facility. Interviews with the Occupational Therapist and the Director of Nursing confirmed that R501 should have been seen at least three times a week as per the therapy plan. The facility's policy on Rehabilitation Therapy and Services, which was reviewed in 2022, states that therapy should be provided according to physician orders and be necessary to improve or maintain the resident's condition. The failure to adhere to these orders and the therapy plan resulted in missed therapy sessions for R501, contributing to the resident's dissatisfaction with the care provided.
Failure to Administer Glucagon for Hypoglycemia
Penalty
Summary
The facility failed to implement appropriate interventions for a resident experiencing hypoglycemia, which led to the resident's hospitalization and subsequent death. The resident, who had a diagnosis of End Stage Renal Disease and Type 2 Diabetes, was found unresponsive with a blood glucose level of 35. Despite having physician orders to administer glucose or glucagon for blood sugar levels below 70, the facility did not administer glucagon before the arrival of emergency medical services (EMS). The resident had received insulin earlier that morning, and there was no documentation of glucagon administration. Interviews with staff revealed that the resident was found unconscious, and CPR was initiated until EMS arrived. The Director of Nursing confirmed that glucagon was not administered, despite it being available in the backup medication system. The facility's diabetic protocol required immediate treatment for hypoglycemia, but the staff did not follow these guidelines. The resident was transported to the hospital with a glucose level of 13 and a chief complaint of cardiac arrest.
Failure to Provide Accurate Transfer Documentation
Penalty
Summary
The facility failed to provide accurate resident identifying documents and medical records during an emergency transfer to the hospital for one resident. This deficiency was identified through interviews and record reviews, revealing that the resident, who had cognitive impairment and pertinent diagnoses including End Stage Renal, Type 2 Diabetes, and Dysphagia, was transferred to the hospital due to a change in mental status and blood pressure monitoring. However, the necessary documentation, including the SBAR Communication Form and face sheet, was not correctly sent with the EMS personnel. Interviews with facility staff, including an LPN and the DON, confirmed that incorrect paperwork was sent with the resident during the transfer. The DON reported that two nurses were involved in the transfer process, and one of them mistakenly printed and provided the wrong paperwork to EMS. This error was only discovered when the hospital contacted the facility hours later to report that they had received another resident's information instead of the correct details for the transferred resident.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to immediately report an allegation of sexual abuse involving two residents, R601 and R603. R601, who was admitted with diagnoses including anxiety, bipolar disorder, and paranoid schizophrenia, had no cognitive impairment as indicated by a BIMS score of 15 out of 15. A progress note dated 4/18/24 documented an incident from the previous night where R601 was reportedly touched under her shirt by another resident, R603. R603, who was legally blind and had a depressed mood and adjustment disorder, also had no cognitive impairment with a BIMS score of 15 out of 15. Despite the incident occurring on 4/17/24, it was not reported to the State Agency (SA) until 4/22/24 by the Nursing Home Administrator (NHA). The NHA, during an interview on 6/6/24, stated that the incident was not reported immediately because she did not consider it an allegation of abuse. However, the facility's policy on Abuse, Neglect, and Exploitation, revised on 1/10/24, requires that allegations involving abuse be reported immediately, but not later than two hours after the allegation is made. The failure to report the incident in a timely manner resulted in unreported allegations of abuse and the potential for further allegations to go unreported.
Failure to Implement Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to implement adequate interventions in a timely manner for a resident deemed to be at very high risk for pressure ulcers, resulting in the worsening of an existing stage 4 pressure ulcer. The resident, who had severe cognitive impairment and multiple medical conditions including end-stage renal disease and MRSA, was admitted with a stage 4 pressure ulcer on the sacral region. Despite the hospital discharge instructions specifying that the wound should be cleaned and dressed twice daily and as needed, the facility did not consistently follow these orders. The wound care nurse did not document all dressing changes, and there were instances where the dressing was not changed after the resident had a bowel movement, which was necessary to maintain wound cleanliness and integrity. The resident's clinical records showed a significant increase in the size of the sacral wound within a week, indicating that the wound care provided was insufficient. The wound measurements increased from 7.4 cm in length, 5.2 cm in width, and 4.5 cm in depth to 12.3 cm in length, 13.1 cm in width, and 5.2 cm in depth. The percentage of slough in the wound also increased from 50% to 60%. The facility's documentation revealed that the wound care nurse did not complete all scheduled dressing changes, and there was a lack of documentation for additional dressing changes that should have been performed after bowel movements. Interviews with the wound care nurse and the Director of Nursing confirmed that the wound care orders were not fully followed, and the necessary documentation was incomplete. The resident's death certificate indicated that septic shock and an infected sacral decubitus ulcer were the direct causes of death, with the chain of events leading to death beginning approximately 14 days prior. The facility's policy on pressure injury prevention and management emphasized the need for prompt assessment and treatment, but this was not adequately implemented for the resident, leading to the worsening of the pressure ulcer and contributing to the resident's death.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician and report abnormally elevated blood sugar levels for a resident with diabetes mellitus, resulting in the physician not having the opportunity to timely participate in medical decisions regarding care and treatment. The resident, who had multiple complex diagnoses including end-stage renal disease, acute respiratory failure, and type 2 diabetes mellitus, had a care plan that included monitoring glucose levels per orders. The physician's orders specified that for blood sugars above 401, the physician should be called. However, on January 17, 2024, the resident's blood sugar values were recorded as 459 and 436 at 12:00 AM and 6:00 AM, respectively, and the physician was not notified as required by the orders. During interviews, the LPN stated that nurses are to follow the guidelines for contacting the physician based on the physician's orders, and the DON confirmed that the physician should have been notified about the hyperglycemia. The DON reviewed the clinical record and acknowledged that there was no documentation indicating that the physician had been called. The failure to notify the physician about the elevated blood sugar levels was identified as a deficiency during the survey, and the facility did not provide any additional documentation or information to address this issue during the exit conference.
Failure to Accurately Reflect Diabetes Status in Physician's Assessment
Penalty
Summary
The facility failed to ensure a physician's assessment accurately reflected the current diabetes mellitus status for one resident, resulting in the potential for delayed execution of appropriate medical treatments and medical needs. The resident, who had a diagnosis of type 2 diabetes mellitus with diabetic peripheral angiopathy, was observed to have fluctuating blood sugar levels that were not adequately addressed by the physician. Despite the resident's blood sugar levels frequently exceeding 150 mg/dl, the physician's notes were repetitive and did not reflect an updated assessment or adjustment in the resident's care plan. The resident's Medication Administration Record (MAR) for February and March 2024 showed that blood sugar levels were monitored multiple times a day, with many readings above the threshold that would typically require insulin coverage. However, the scheduled insulin and additional insulin coverage had been discontinued. The physician's notes from February and March 2024 were found to be repetitive and did not indicate any new evaluation or adjustment based on the resident's current condition. Interviews with the Unit Manager and the Director of Nursing (DON) revealed concerns about the physician's lack of updated assessment and the repetitive nature of the clinical notes. The physician admitted to not being aware of any acute episodes regarding the resident's diabetes and stated that he should be contacted by the facility if blood sugars are low or high. The facility's policy on physician visits emphasized the need for active supervision and evaluation of the resident's condition, which was not adhered to in this case.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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