The Oaks At Woodfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Blanc, Michigan.
- Location
- 5370 East Baldwin Road, Grand Blanc, Michigan 48439
- CMS Provider Number
- 235660
- Inspections on file
- 19
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Oaks At Woodfield during CMS and state inspections, most recent first.
The facility did not ensure care plans accurately reflected residents' specific code status preferences or the use and management of specialized equipment. Several residents had advance directives or equipment in use that were not clearly documented or specified in their care plans, and staff interviews revealed confusion about care plan responsibilities and documentation.
Surveyors found expired and unlabeled glucose control solutions, undated wound care supplies, and medications without resident identification in medication rooms and carts. Keys to treatment carts containing prescription medications were left accessible, and nurse aides were allowed unsupervised access to the medication room, where the refrigerator with insulin and vaccines was unlocked. Staff interviews confirmed that these practices did not follow facility policy or professional standards.
Several residents did not receive timely or preferred ADL care, including missed scheduled showers, bed baths given instead of showers, and lack of grooming such as nail trimming and shaving. Residents with chronic conditions and cognitive intactness expressed their preferences for showers and grooming, but records and observations showed these preferences were not followed, resulting in greasy hair, long toenails, and unshaven facial hair.
The facility did not ensure that hospice records and communication were consistently included in the medical records for two residents receiving hospice services. For both residents, hospice visit notes and documentation of care provided were either missing from the medical record or only made available in hard copy after the fact, rather than being integrated into the ongoing record. One resident also reported concerns to hospice about the care received, particularly related to ileostomy and wound care.
The facility did not consistently obtain and monitor weights as ordered for two residents with complex medical needs, resulting in missed and inconsistent weight recordings despite physician orders and care plan requirements. Significant weight fluctuations were not properly addressed, and recommended monitoring was not implemented after notable changes.
A resident requiring regular dialysis was not informed or offered the facility's free transportation service, which was included in the bundled payment. Instead, the resident's family was left to arrange and provide transportation to and from dialysis appointments, without being given the option to use the facility's service. Staff interviews confirmed that transportation should have been provided and that the lack of communication led to the deficiency.
The facility did not complete required hydrostatic testing for kitchen fire suppression system cylinders, which were marked as unsatisfactory during the last two semi-annual inspections. The cylinders, installed in 2012, had not been tested at the required 12-year interval, as confirmed by the maintenance director.
A portable space heater was found on the desk in the DON's office, and staff could not verify that its heating element did not exceed the regulatory limit of 212°F. This was confirmed by the maintenance director during the survey, resulting in a deficiency for noncompliance with NFPA 101 requirements regarding portable space heaters in health care occupancies.
The facility failed to complete baseline care plans within 48 hours for two residents, resulting in falls and unmet care needs. One resident experienced multiple falls due to a delayed care plan, while another had a skin impairment that was not addressed promptly.
The facility failed to ensure timely dressing changes for two residents, resulting in missed dressing changes and the potential for worsening wounds. One resident had a wound dressing that was not changed for 10 days, while another had an unlabeled and undated drain dressing. The facility's policy lacked specific guidelines for post-surgical drains.
The facility failed to ensure appropriate interventions and supervision to prevent falls for two residents, resulting in significant injuries. One resident experienced multiple falls due to missed pharmacy recommendations to change medication, while another resident fell and fractured his hip after being left unsupervised.
A resident with Parkinson's Disease experienced significant weight loss due to insufficient food and lack of feeding assistance. The facility failed to update the care plan or notify the registered dietician, resulting in potential health risks.
The facility failed to ensure timely review of drug regimen recommendations for a resident, resulting in the resident receiving a potentially inappropriate medication and experiencing multiple falls. The pharmacist's recommendations to change the medication were not promptly addressed, leading to continued use of the medication and subsequent falls.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop person-centered, comprehensive care plans that accurately reflected the specific needs and preferences of four residents. For three residents with documented advance directives, the care plans did not specify the residents' chosen code status, despite this information being available in the medical record and flagged on the face sheet. For example, one resident was identified as Full Code in both the physician orders and face sheet, but the care plan only generically referenced code status without specifying Full Code. Another resident's care plan mentioned advanced directives but did not state the resident's DNR preference, and a third resident's care plan referenced comfort care and hospice services but omitted the code status preference, even though the face sheet indicated DNR. Additionally, for a resident on hospice with a history of stroke and pressure ulcers, the care plan referenced the use of a low air loss mattress but did not include an order or directive for the alternating pressure mattress that was in use. There was also no documentation available to staff regarding the appropriate settings for the air mattress, and the care plan did not reflect the actual equipment or its management. Interviews with staff revealed uncertainty about who was responsible for care plan completion and a lack of clarity regarding the documentation and communication of equipment settings.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage and labeling practices. In the 200 Hall medication storage room, expired Assure Prism glucose control solutions were found, with no open dates on the bottles or boxes, and no unexpired control solutions available. Additionally, medications in bubble packaging were found in a medication cart without any identifying information such as resident name or room number. The nurse present was unable to identify the owner of these medications and indicated that they would use the medication since it had already been signed out for a resident. In the 300 Hall medication room, opened betadine solution and wound dressings were found without open dates, and a white powder residue was observed on one bottle. Glucose test strips were also found opened and undated, contrary to facility policy as described by the nurse. Further observations revealed that keys to the treatment cart, which contained prescription medications and treatment supplies, were left on top of the cart and accessible to multiple staff members. The nurse explained that due to having only one set of keys, they were left with the cart for shared access. The treatment cart contained various prescription medications and wound care supplies. Additionally, a nurse aide was observed being given keys to the medication room to retrieve an ice pack, entering the room unattended. The medication refrigerator inside the room, which contained insulin pens and vaccinations, was found unlocked, and nurse aides were allowed to access the room without supervision, contrary to the statements of the nurse supervisor. Interviews with nursing staff and the Director of Nursing confirmed that medication storage and access practices did not align with facility policy or professional standards. Staff acknowledged that items such as glucose control solutions, test strips, and wound care supplies should be dated when opened, and that medication carts and rooms should remain secure. The lack of proper labeling, storage, and security for medications and biologicals was consistently observed across multiple medication rooms and carts.
Failure to Provide Timely and Preferred ADL Care
Penalty
Summary
The facility failed to provide timely and appropriate Activities of Daily Living (ADL) care, including bathing and grooming, to several residents who required assistance. One resident, recently admitted with cellulitis, diabetes, and osteomyelitis, reported not receiving showers as scheduled and instead often received bed baths, despite a clear preference for showers. Documentation showed missed scheduled shower days and a lack of adherence to the resident's care plan, which specified showers twice weekly. The resident was observed with greasy hair, and staff interviews confirmed a lack of understanding regarding the difference between bed baths and partial bed baths. Another resident with multiple chronic conditions, including diabetes and depression, was observed with very long and jagged toenails, despite physician orders for nail clipping on shower days. The resident's care plan called for showers twice weekly and regular nail trimming, but records indicated only three showers were provided over a month. The resident expressed discomfort due to the length of her toenails, which were observed by staff and visitors, and reported a fear of nail clipping due to a previous bad experience. A third resident, admitted for rehabilitation after a hospital stay, had not received a shower since admission and expressed a strong preference for showers over bed baths. The resident's care plan required showers twice weekly, but records showed only one shower and multiple bed baths during the stay. The resident also had unshaven facial hair, which he did not prefer, and reported that no one had offered to shave him. Staff and documentation confirmed the lack of adherence to the resident's bathing and grooming preferences.
Failure to Maintain Hospice Documentation in Medical Records
Penalty
Summary
The facility failed to ensure that hospice records and communication were consistently included in the medical records for two residents receiving hospice services. For one resident with a history of stroke, cognitive communication deficit, hemiplegia, and a pressure ulcer, there was no documentation in the medical record of hospice communication, progress notes, or records of hospice visits and care provided. The hospice folder for this resident contained only general information and a care plan, but lacked visit documentation. The Assistant Director of Nursing confirmed that only social work staff could access hospice information through a portal, and other staff did not have access. For another resident with multiple diagnoses including spina bifida, heart failure, diabetes, and a stage 4 pressure ulcer, hospice services were reported by the resident and staff, but hospice notes and visit documentation were not found in the electronic medical record or in the hospice chart at the nurses' station. When a binder with hospice documents was eventually provided, it contained notes that were all printed on the same day, rather than being integrated into the ongoing medical record. The resident had also expressed concerns to hospice about the care received, specifically regarding ileostomy and wound care.
Failure to Consistently Obtain and Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to consistently obtain and monitor weights as ordered for two residents reviewed for nutrition. One resident, with multiple diagnoses including diabetes and chronic pain, had weights recorded inconsistently and not according to the physician's order for monthly weights by the 5th of each month. Significant weight fluctuations were noted, including a loss of 6.2 lbs over 11 days and a total loss of 10 lbs over approximately six weeks. The electronic medical record flagged an out-of-range weight, and the registered dietitian recommended weekly weights after a significant loss, but these were not obtained as recommended. The resident expressed distress about the reported low weight, stating she had never weighed below 100 lbs. Another resident, with diagnoses including congestive heart failure, chronic kidney disease, and dementia, had a physician's order for daily weights due to their medical condition and dialysis requirements. However, there were missing weight entries on three separate days, and the nurse's notes did not reflect any weights recorded on those dates. The care plan for this resident included goals to prevent unwarranted weight gain and maintain appropriate weight for dialysis, with the approach to obtain weights as ordered, which was not consistently followed.
Failure to Inform and Provide Dialysis Transportation Services
Penalty
Summary
The facility failed to inform and offer transportation services to and from dialysis appointments at no cost for a resident requiring dialysis, as part of the bundled services. The resident, who was cognitively intact and admitted with multiple diagnoses including acute renal failure, chronic kidney disease, and dementia, was scheduled for dialysis three times a week. The care plan indicated that the family was responsible for transportation, but there was no documentation that the facility had discussed or offered its own transportation services, which were included in the bundled payment and available at no extra charge. The resident's family expressed concern and confusion about why they were required to provide transportation, stating that no one from the facility had discussed this option with them upon admission. Interviews with facility staff, including the LPN, Social Services Director, and Administrator, confirmed that transportation for dialysis was a service provided by the facility and should have been offered to the resident and family. The Administrator acknowledged that there was a lack of communication regarding this service and that the family was not given the choice to use the facility's transportation. Facility policy also stated that the campus is responsible for arranging or providing transportation to and from the dialysis provider, but this procedure was not followed in this case.
Overdue Hydrostatic Testing of Kitchen Fire Suppression Cylinders
Penalty
Summary
The facility failed to ensure that its cooking facilities were protected in accordance with NFPA 96 standards. Record review on May 7, 2025, revealed that the wet chemical fire suppression system in the kitchen was past due for hydrostatic testing of the agent cylinders. Documentation from the facility's vendor indicated that the cylinders were marked as unsatisfactory during the last two semi-annual inspections. The cylinders, which were installed in 2012, require hydrostatic testing every 12 years, but this had not been completed. These findings were confirmed during an interview with the maintenance director at the time of the record review.
Plan Of Correction
K324 - Cooking Facilities Element 1: The Campus obtained a 12-year hydrostatic testing and recharge of agent cylinders on the wet chemical fire suppression system, on 5/22/2025. Element 2: A one-time audit was completed to ensure records of the system inspection were obtained and compliant. Element 3: Education was provided to the Director of Plant Operations on May 29, 2025, by the Executive Director to ensure timely and compliant inspections of the wet chemical fire suppression systems. Element 4: DPO/Designee will audit monthly x4 to ensure record of completion is present and compliant on the semi-annual inspection documents. Element 5: ED or designee will be responsible for substantial compliance. The Facility will be in substantial compliance by June 10, 2025.
Noncompliant Use of Portable Space Heater in Staff Office
Penalty
Summary
A portable space heater was observed on the desk in the Director of Nursing's office during a facility inspection. The space heater's heating element could not be verified as not exceeding 212 degrees Fahrenheit, which is a requirement for use in nonsleeping staff and employee areas according to NFPA 101 19.7.8.1. This observation was confirmed through an interview with the maintenance director at the time of the survey. The presence of the space heater in a health care occupancy area constitutes a failure to comply with regulations prohibiting such devices unless specific safety criteria are met.
Plan Of Correction
K781- Portable Space Heaters Element 1: The Campus removed the portable space heating device from the Director of Nursing office immediately upon identification. Element 2: A one-time audit was completed to ensure there were no other portable space heating devices in office spaces. Element 3: Remedial education was immediately provided to the Interim Director of Health Services regarding portable space heaters, on May 7, 2025. Element 4: DPO/Designee will audit weekly x 3 and monthly x 4 to ensure there are no portable space heating devices in health care occupancies. Element 5: ED or designee will be responsible for substantial compliance. The Facility will be in substantial compliance by June 10, 2025.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for two residents, resulting in incomplete baseline care plans, falls, and unmet care needs. Resident #2, who was admitted with a right lower leg fracture, Alzheimer’s disease, dementia, and metabolic encephalopathy, experienced multiple unwitnessed falls since admission. Despite being assessed as high risk for falls, a care plan and interventions were not put in place until over a month later. The Minimum Data Set (MDS) nurse confirmed that the care plan for falls should have been included in the baseline care plan but was missed. Resident #40, admitted with Alzheimer’s dementia, rheumatoid arthritis, hypertension, weakness, anemia, and dizziness, had redness on the right great toe upon readmission. However, there was no care plan addressing this issue until over 72 hours later. The nurse who completed the admission assessment noted the redness but did not include any orders for treatment or monitoring in the care plan. This delay in care planning resulted in the resident's skin impairment not being addressed in a timely manner.
Failure to Ensure Timely Dressing Changes
Penalty
Summary
The facility failed to ensure timely dressing changes for two residents, resulting in missed dressing changes and the potential for worsening wounds. Resident #5, who was admitted with multiple diagnoses including a right humerus fracture, heart failure, dementia, dysphagia, and hypertension, had a wound dressing on the left shin that was not changed for 10 days. The dressing, dated 4/7, was found leaking blood on 4/17, and upon removal, green-colored drainage was present. The Director of Nursing (DON) acknowledged the error, stating the dressing was supposed to be dated 4/17, but the large amount of drainage indicated otherwise. Photographic evidence provided by the complainant supported these findings, showing the dated dressing and the exposed wound with purulent drainage. Resident #117, admitted for a short-term stay and on antibiotic therapy after abdominal surgery, had a drain dressing on the right side of the abdomen that was not labeled or dated. The resident did not know when the dressing was last changed, and the drainage bag attached to the tube contained yellowish-to-brownish fluid. The Infection Control Nurse confirmed the lack of labeling and dating and noted that the respiratory treatment apparatus was not stored in a sanitary manner. A review of the resident's electronic medical record revealed no specific treatment order for the abdominal wound drain, and the facility's policy did not include guidelines for assessing or changing wound drain dressings. The facility's policy for wound dressing changes, dated 5/10/2016, was reviewed and found to lack specific guidance for post-surgical drains or abdominal wound drains. The policy only provided guidelines for skin tears and lacerations, requiring weekly follow-up assessments to ensure healing. The absence of a comprehensive wound care policy and the failure to adhere to existing dressing change orders led to the deficiencies observed in the care of Residents #5 and #117.
Failure to Prevent Falls Resulting in Injuries
Penalty
Summary
The facility failed to ensure appropriate interventions and supervision to prevent falls for two residents, resulting in significant injuries. Resident #15, who had multiple diagnoses including an above-the-knee amputation and dementia, experienced several falls between January and March 2024. Despite pharmacy recommendations to change the resident's medication due to its potential to cause falls, the facility did not act on these recommendations in a timely manner. The resident continued to fall, sustaining injuries including an abrasion and bleeding from the nostrils after a fall on March 28, 2024. The Director of Nursing acknowledged that the pharmacy recommendations were missed and not followed up on until mid-April 2024, after the resident had already experienced multiple falls and injuries. Resident #52, who had Parkinson's Disease and was at high risk for falls, fell on March 16, 2024, while left unsupervised in a day room. The resident sustained a displaced intertrochanteric fracture of the left hip, requiring surgical intervention. The resident's care plan included placing him in a common area for easier observation, but no staff were present to supervise him at the time of the fall. The nurse assigned to the resident admitted to leaving him unattended while she passed medications, and the call light was not accessible to the resident. The Director of Nursing confirmed that the fall was unwitnessed and that the facility did not report the incident to the state. Both residents had care plans that were either not followed or inadequately updated to reflect their high fall risk. Resident #15's care plan included interventions for psychotropic drug use but did not address the pharmacy's recommendations to change the medication. Resident #52's care plan was not updated promptly after previous falls, and the intervention to place him in a common area without direct supervision proved ineffective. The facility's failure to implement and follow appropriate interventions and supervision led to significant injuries for both residents.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that weight loss was monitored, addressed with updated nutritional interventions, and notify the registered dietician of the weight loss for one resident. Resident #52, who has Parkinson's Disease and other significant health issues, reported that the food provided was insufficient and that he was losing weight. His friend, who often visited, noted that Resident #52 was not receiving adequate feeding assistance or adaptive utensils to help with his tremors during meals. Despite these observations, the facility did not update the resident's nutritional care plan or notify the registered dietician about the weight loss. A review of Resident #52's medical records showed a significant weight loss over a period of time, from 164.6 lbs on admission to 156.2 lbs. The resident's care plan, which was last reviewed on 4/2/24, did not include any updates or additional interventions to address the weight loss, despite the resident's fall, hip fracture, and decreased ability to perform activities of daily living. The facility's weight monitoring policy requires a review of 5% weight changes, but the Director of Nursing and the Registered Dietician both indicated that the resident's weight loss did not trigger a red flag for significant weight loss. During an interview, the resident's family expressed concerns about the lack of communication and care planning to address the resident's nutritional needs. The family was not aware of any care conferences to discuss the resident's eating habits and food preferences. The facility's failure to monitor and address the resident's weight loss, update the care plan, and notify the registered dietician resulted in the potential for continued rapid weight loss and compromised health condition for Resident #52.
Failure to Address Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that drug regimen review recommendations were reviewed by the physician in a timely manner for one resident, resulting in the resident receiving a medication with potential adverse effects, including falling. Resident #15, who had multiple diagnoses including depression, anxiety, and dementia, experienced several falls at the facility. The pharmacist made recommendations on two occasions to change the resident's medication for depression, as it was potentially inappropriate for the elderly and could lead to falls. These recommendations were not promptly addressed by the physician, leading to continued use of the medication and subsequent falls by the resident. The first recommendation was made on 1/25/2024, but it was not properly followed up on, and the resident continued to fall on multiple occasions. The second recommendation was made on 3/31/2024, and it was not until 4/16/2024 that the recommendation was signed, and a new medication order was initiated on 4/18/2024. The Director of Nursing confirmed that the initial recommendation was missed and not followed up on, and the facility was working to ensure that pharmacy recommendations were not missed again.
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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