The Orchards At Armada
Inspection history, citations, penalties and survey trends for this long-term care facility in Armada, Michigan.
- Location
- 22600 Armada Ridge Road, Armada, Michigan 48005
- CMS Provider Number
- 235609
- Inspections on file
- 24
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Orchards At Armada during CMS and state inspections, most recent first.
A resident with a chronic right lower extremity ulcer experienced progressive wound deterioration after a wound vac was replaced with an Unna boot, with documentation of increasing pain, edema, warmth, erythema, foul-smelling drainage, necrosis, and new lesions. Although the primary MD adjusted antibiotics and ordered detailed wound care, and nursing and wound care staff noted worsening signs of infection, the facility did not document any contact with the outside wound care specialist directing the resident’s wound care. The Treatment Administration Record lacked documentation of wound treatments, and interviews confirmed that facility staff understood it was their responsibility to notify the consulting specialist but did not do so until the resident’s next follow-up visit, when the specialist sent the resident to the ER for a wound infection.
Surveyors observed that the required circuit breaker locking device was not installed in the circuit breaker panel for the fire alarm booster module in the Mechanical Room (Memory Care). This deficiency was confirmed by the Maintenance Director and could impact all residents in the facility.
Surveyors found that the required evacuation map was missing in the Maple Ridge corridor, which is necessary for identifying locations and evacuation routes. This deficiency was confirmed with the Maintenance Director and could impact 26 of 64 residents during an emergency evacuation.
A volunteer was observed standing while feeding a resident with dementia and dysphagia and intermittently assisting another resident, contrary to the care plan and facility policy requiring one-to-one, seated feeding assistance to maintain dignity.
A resident receiving daily IV antibiotics via a PICC line was found with a dressing that included gauze under a transparent covering, which had not been changed according to facility policy. During IV medication administration, a nurse was observed attempting to connect tubing containing multiple air bubbles, which was only corrected after noticing the issue. The DON confirmed that both the dressing change interval and air bubble management did not meet professional standards of practice.
Two residents experienced lapses in infection prevention and control when a nurse failed to use required PPE during PICC line care and a volunteer did not perform hand hygiene between assisting residents during meals, contrary to facility policy and established protocols.
The facility failed to ensure opened food items were properly dated and discarded when expired, and did not maintain the ice machine filter. Several undated and expired food items were found in the kitchen and resident refrigerator, and ants were observed in the activity cabinet.
A facility failed to revise the care plan for a resident with Dysphagia and Aphasia. The resident, with impaired cognition, was observed eating without required assistance and had fluids with a straw at bedside, contrary to the care plan. The Registered Dietitian confirmed a change in liquid intake, but the care plan was not updated.
The facility failed to provide necessary meal assistance and proper positioning for two residents, resulting in inadequate nutritional intake and care. One resident was left unattended with uneaten meals despite needing help, while another did not receive the required 1:1 feeding assistance as per their diet order.
The facility failed to apply heel protectors and lids to drinks per physician orders for a resident with muscle weakness, difficulty in walking, and impaired cognition. Despite staff education and physician orders, the resident was repeatedly observed without heel protectors and with drinks that did not have lids.
A resident with an indwelling urinary catheter was observed multiple times without a leg strap to secure the catheter, and the drainage tubing was often found looped and on the floor. Despite the facility's policy requiring securement and proper positioning, these guidelines were not followed, leading to deficiencies in care.
The facility failed to provide timely assistance to residents, with multiple instances of call lights being activated for extended periods without response. Residents reported frequent delays of over an hour for assistance, and staff interviews confirmed that the facility was often understaffed, particularly on weekends. Observations and schedule reviews corroborated these findings, highlighting significant delays in meeting residents' needs.
The facility failed to administer medications per manufacturer recommendations and physician orders, resulting in a 7.89% medication error rate. An LPN administered cholestyramine with other medications, did not administer Doptelet as prescribed, and substituted a Lidoderm patch with a menthol patch without a physician's order.
The facility failed to provide a resident with food items in a puree consistency as prescribed. Observations revealed the resident was given scrambled eggs, oatmeal, hard pretzels, and a regular piece of frosted cake, none of which were consumed. The diet order specified a pureed texture and thin liquid consistency, which was not followed.
A facility failed to wear proper PPE for a resident under Enhanced Barrier Precautions (EBP). An RN was observed entering and exiting the resident's room without appropriate PPE, despite an EBP sign and cart being present. The resident had a history of chronic urinary tract infections and required assistance with bed mobility and transfers. The RN was unaware of the specific reason for the EBP, indicating a lapse in following infection control protocols.
Failure to Notify Consulting Wound Specialist of Worsening Wound Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify and consult the outside wound care clinic consulting specialist (WCCCS) regarding a resident’s deteriorating right lower extremity wound, despite clear signs of infection and decline. The resident was admitted with a chronic ulcer of the right ankle and varicose veins of the right lower extremity with ulcer, and initially had a wound vac in place per the WCCCS. After a follow-up visit, the wound vac was removed and an Unna boot was ordered. In the days that followed, clinical documentation showed increasing edema, redness, warmth, and an elevated white blood cell count, and the primary medical doctor (PMD) changed antibiotics and ordered specific wound care treatments while noting they had spoken with the WCCCS about the plan of care. However, there was no documentation that the facility actually consulted or updated the WCCCS about the wound’s deterioration during this period. Progress notes over the next several days documented the resident’s increasing pain, edema, warmth, drainage, erythema, foul-smelling yellowish drainage, saturated dressings, and surrounding redness and warmth suggestive of cellulitis and wound infection. A wound care nurse later documented increased ulceration, slough/necrosis, heavy serous and purulent drainage, bright yellow thick purulence expressed with light pressure, and a new purple fluid-filled lesion with peri-wound erythema and pain, with notification only to the wound care nurse practitioner. Interviews with the PMD and wound care nurse practitioner confirmed that they did not assume responsibility for contacting the outside consulting provider and that it was the facility’s responsibility to notify the WCCCS of wound deterioration. The clinical record lacked documentation of any wound treatments on the Treatment Administration Record for the month and contained no evidence that the WCCCS was consulted about the worsening wound until the resident’s subsequent follow-up visit, when the WCCCS sent the resident to the emergency room for a wound infection.
Missing Circuit Breaker Locking Device for Fire Alarm Booster Module
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program that complies with NFPA 70 and NFPA 72. During an observation in the Mechanical Room (Memory Care), it was found that the required circuit breaker locking device was not provided in the circuit breaker panel for the installed fire alarm booster module. This omission was confirmed through an interview with the facility Maintenance Director at the time of observation. The lack of the locking device could potentially allow for unauthorized tampering with the fire alarm system, and this deficiency could affect all 64 residents in the facility.
Plan Of Correction
ELEMENT 1 The circuit breaker locking device has been placed on in the circuit breaker panel in the Mechanical room on Orchard View. ELEMENT 2 The Maintenance Director and/or designee did an audit on all circuit breaker panels in the facility to ensure there is a locking device present. Any areas of noncompliance were addressed immediately. ELEMENT 3 The Maintenance Director has been reeducated to ensure that the required circuit breaker locking device in the circuit breaker panel mechanical room for our installed fire alarm booster module on Orchard View is present. ELEMENT 4 The Maintenance Director/designee will conduct weekly audits for 2 months to ensure that the required circuit breaker locking device in the circuit breaker panel mechanical room for our installed fire alarm booster module on Orchard View is present. ELEMENT 5 Date of compliance 06/27/2025. The Maintenance Director and/or designee will be responsible for sustained compliance.
Missing Evacuation Map in Corridor
Penalty
Summary
The facility failed to provide the required evacuation map in the Maple Ridge corridor, as observed during a survey. The evacuation map is necessary to identify locations within the facility and to highlight designated evacuation routes to the exterior of the building. This deficiency was confirmed through observation and interview with the Maintenance Director. The lack of an evacuation map could affect 26 of 64 residents in the event of a fire or other emergency requiring area evacuation. Employees were not periodically instructed in their duties under the evacuation plan as required by regulatory standards, and the written plan for the protection and evacuation of all residents was not fully implemented in this area.
Plan Of Correction
ELEMENT 1 On 6/27/25 an evacuation map was placed on Autum Ridge to identify the current location within the facility and highlight designated evacuation routes to the exterior of the facility. ELEMENT 2 Rounds were conducted by the Maintenance Director and/or designee on all fire corridors to ensure there are evacuation maps present. ELEMENT 3 The Maintenance Director has been reeducated on maintaining evacuation maps throughout the building in all fire corridors. ELEMENT 4 The Maintenance Director/designee will conduct weekly audits for 1 month to ensure all fire corridors have the required evacuation maps. ELEMENT 5 Date of compliance 06/27/2025. The Maintenance Director and/or designee will be responsible for sustained compliance.
Failure to Provide Dignified Feeding Assistance
Penalty
Summary
A deficiency was identified when a volunteer was observed providing feeding assistance to a resident with dementia and dysphagia in the memory care unit dining room. The volunteer stood while feeding the resident and intermittently attended to another resident, rather than providing dedicated one-to-one assistance. The resident's care plan and physician orders specified the need for one-to-one feeding assistance, aspiration precautions, and that the resident should remain upright in a chair during feeding. The Director of Nursing confirmed that the facility's expectation is for staff to sit with residents while providing one-to-one feeding assistance and to avoid assisting more than one resident at a time to maintain dignity. Facility policy also directs staff not to stand while feeding residents. The observed actions did not align with these expectations or the resident's care plan, resulting in a failure to provide feeding assistance in a dignified manner.
Plan Of Correction
ELEMENT 1 Resident R15 still resides in the facility and continues to be assisted with feeding by staff and/or volunteers that have been reeducated to stay seated while assisting to feed as well as only assisting one resident at a time. ELEMENT 2 Residents that reside in the facility have the potential to be affected. An audit was done on residents residing in the facility that require assistance with meals to ensure they are being assisted by a staff member and/or volunteer that remains seated and only assisting one resident at a time. Any areas of deficiency at the time of the audit will be corrected immediately. ELEMENT 3 The Resident Rights policy was reviewed by the DON and the Administrator and deemed appropriate. The staff and volunteers were reeducated on remaining seated while assisting residents with eating as well as assisting one resident at a time. ELEMENT 4 The DON and/or designee will conduct random audits 2 times a week for 2 months to ensure that staff and/or volunteers are staying seated while assisting residents with meals as well as only assisting one resident at a time. Any areas of deficiency at the time of the audits will be corrected immediately, and the results of these audits will be presented at the facility's QAPI for further recommendations and/or corrective actions. ELEMENT 5 Date of compliance 06/27/2025. The Administrator and/or designee will be responsible for sustained compliance.
Failure to Follow Professional Standards for PICC Line Care and IV Administration
Penalty
Summary
A deficiency was identified when a resident with a peripherally inserted central catheter (PICC) line for daily intravenous (IV) antibiotic administration was observed to have a dressing that included a folded white gauze under a transparent covering, dated several days prior. The resident confirmed that the dressing was being changed weekly, despite receiving daily IV antibiotics. Review of the Treatment Administration Record and Medication Administration Record indicated the last dressing change occurred several days before the observation. Facility policy required site care every 72 hours and as necessary, and the Director of Nursing confirmed that a gauze dressing should be changed within 48 hours. Additionally, the presence of gauze under the transparent dressing prevented direct assessment of the insertion site for signs of infection. During an observed IV medication administration, a registered nurse donned gloves, cleaned and flushed the PICC line, and began to connect the IV tubing. Multiple air bubbles were observed in the tubing, which the nurse noticed and then replaced the tubing before completing the administration. The Director of Nursing acknowledged that air bubbles should be drained prior to connecting IV tubing. These actions demonstrated a failure to follow professional standards of practice for PICC line care and IV medication administration, as required by facility policy and regulatory standards.
Plan Of Correction
Element 1 R42 no longer resides at the facility. Element 2 The residents that reside in the facility have the potential to be affected. An audit was completed on the residents residing in the facility that have PICC lines to ensure when a gauze dressing is used it is to be changed to no longer than 48 hours; and when priming IV lines that contain excessive air bubbles must be consistent with professional standards of practice. Any areas of deficiency at the time of the audit will be corrected immediately. Element 3 The IV Therapy policy was reviewed by the DON and ADON/IC and updated to our pharmacy's "Catheter Insertion and Care" policy and deemed appropriate. The nurses were reeducated on the Pharmacy's policy to ensure when gauze dressings are used, they are to be changed no longer than 48 hours, and when priming IV lines that contain excessive air bubbles must be consistent with professional standards of practice, i.e., fluid must run through the line into a waste receptacle until air is gone or acquire new IV tubing. Element 4 The DON and/or designee will conduct random audits twice a week for 2 months, to ensure nurses are following the "Catheter Insertion and Care". Any areas of deficiency at the time of the audits will be corrected immediately, and the results of these audits will be presented at the facility's QAPI for further review and/or corrective action. Element 5 Date of compliance 06/27/25. The Administrator and/or designee will be responsible for sustained compliance.
Deficient Infection Control in Central Line Care and Meal Assistance
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed during the care of two residents. In one instance, a registered nurse (RN) administered IV medication to a resident with a peripherally inserted central catheter (PICC) line without donning a gown, as required by enhanced barrier precautions. The RN was observed entering the resident's room, which had signage indicating the need for a gown and gloves, but only donned gloves that were taken from their pocket, a practice acknowledged by the RN as an old habit. The resident in question had been admitted with diagnoses including osteomyelitis, discitis, and hepatitis C, and was under enhanced barrier precautions due to the central line. The Director of Nursing (DON) and Infection Control Nurse confirmed that gloves should not be stored in staff pockets and that both gown and gloves are required for such care activities. In another instance, a volunteer providing one-to-one feeding assistance to a resident with dementia and dysphagia failed to perform hand hygiene between assisting the assigned resident and another resident during meal service. The volunteer was observed setting down the resident's utensil, assisting another resident, and then returning to the original resident without washing hands in between. The DON stated that the expectation is for staff providing one-to-one feeding assistance not to assist other residents, but if they do, hand hygiene must be performed between residents. Facility policy on hand hygiene specifically requires hand washing with soap and water before and after assisting a resident with meals. A review of facility policies revealed clear requirements for infection control, including the use of enhanced barrier precautions for central line care and strict hand hygiene protocols during resident meal assistance. Despite these policies and staff training, the observed actions did not align with the established standards, resulting in deficiencies in infection prevention and control practices for the residents involved.
Plan Of Correction
Element 1 R42 no longer resides at the facility, and R15 continues to be assisted by staff and/or volunteers who have been reeducated to perform hand hygiene before and after assisting a resident with meals. Element 2 Residents that reside in the facility have the potential to be affected. An audit was done on the residents with PICC lines to ensure the staff are adhering to Enhanced Barrier Precautions and donning and doffing the appropriate PPE prior to performing any procedures for the PICC line. An audit was done on the residents that require assistance with meals to ensure staff and volunteers only assist one resident at a time and perform hand hygiene before and after assisting any resident. Any areas of deficiencies at the time of the audits will be corrected immediately. Element 3 The Enhanced Barrier Precaution and Hand Hygiene policies were reviewed by the DON and ADON/IC and deemed appropriate. The nurses were re-educated on the Enhanced Barrier Precaution policy and procedures regarding appropriate PPE when taking care of a PICC line. Staff and volunteers were re-educated on the Hand Hygiene policy regarding assistance with meals. Element 4 The ADON/IC and/or designee will complete random audits twice a week for 2 months to ensure nurses are Donning and Doffing appropriate PPE per our policy and procedures while caring for a PICC line. The Administrator and/or designee will complete random audits twice a week for 2 months to ensure that staff and/or volunteers are only assisting one resident at a time and using proper hand hygiene before and after assisting residents with meals. Any areas of deficiencies at the time of the audits will be addressed immediately, and the results of these audits will be presented at the facility's QAPI for further recommendations and/or corrective action. Element 5 Date of compliance 06/27/25. The Administrator and/or designee will be responsible for sustained compliance.
Failure to Properly Date and Discard Food Items and Maintain Ice Machine Filter
Penalty
Summary
The facility failed to ensure that opened food items were properly dated and discarded when expired, and did not maintain the filter for the ice machine. During a tour of the kitchen, several opened food items were found without proper dating, including deli turkey, salami, Caesar dressing, and enchilada sauce. Additionally, an unlabeled bin of white powder, identified as thickener, was found in the dry storage room. The ice machine filter was also found to be outdated. In the resident refrigerator, a container of cut pineapple with an expired use-by date and an undated container of chicken soup were observed. Ants were found crawling on the activity cabinet next to the resident refrigerator. The Dietary Manager confirmed that the undated and expired food items should be discarded and that the thickener should be labeled. The facility's policy on the safe storage and handling of outside food was reviewed, noting that any food not consumed immediately must be covered and labeled with the resident's name and date. The presence of ants in the activity cabinet was acknowledged by the activity staff, who stated they would inform Maintenance. These deficiencies were identified based on observations, interviews, and record reviews conducted by the surveyors.
Failure to Revise Care Plan for Resident with Dysphagia and Aphasia
Penalty
Summary
The facility failed to revise the care plan for a resident diagnosed with Dysphagia following Cerebral Infarction and Aphasia. The resident, who had an impaired cognition score of 2/15, was observed attempting to eat pureed food without the required 1:1 assistance. Additionally, the resident was repeatedly observed with fluids and a straw at their bedside, contrary to the care plan's intervention of no straws and no fluids at bedside. The Registered Dietitian confirmed that the resident's liquid intake had been changed to thin liquids, but the care plan was not updated to reflect this change, violating the facility's policy on re-evaluating and modifying care plans as necessary to reflect changes in care, service, and treatment.
Failure to Provide Meal Assistance and Proper Positioning
Penalty
Summary
The facility failed to ensure meal assistance and proper positioning for two residents, leading to deficiencies in their care. Resident R53 was repeatedly observed in a supine position, leaning to one side, with uneaten meal trays left untouched. Despite being frail, underweight, and requiring assistance with eating, staff did not provide the necessary help or encouragement. The resident's care plan lacked specific instructions for meal assistance, and staff failed to monitor and assist the resident adequately, resulting in poor nutritional intake over several days. Resident R56, diagnosed with dysphagia and aphasia, was observed attempting to eat without the required 1:1 feeding assistance. Despite a diet order specifying the need for slow feeding with small bites, no staff were present to assist during multiple observations. Interviews with staff revealed inconsistencies in understanding and implementing the resident's dietary needs, with some staff stating the resident could self-feed with cues, while others noted the resident's refusal to be fed. The facility's policies on resident assistance during meals and comprehensive care planning were not followed, leading to inadequate care for both residents. The lack of proper assistance and monitoring during meals, as well as the failure to update and implement care plans, contributed to the observed deficiencies in the residents' care.
Failure to Follow Physician Orders for Heel Protectors and Drink Lids
Penalty
Summary
The facility failed to apply heel protectors and lids to drinks per physician orders for one resident. On multiple occasions, the resident was observed in bed without heel protectors and with drinks that did not have lids, despite physician orders requiring these measures. The resident, who has muscle weakness, difficulty in walking, and impaired cognition, was noted to have their heels resting on the mattress without protection and was provided beverages without lids or handles. These observations were made over several days, indicating a consistent failure to follow physician orders. Interviews with staff revealed that the resident often refuses to wear heel protectors, but this refusal was not documented as required. The Director of Nursing confirmed that staff had been educated on the importance of ensuring drinks have lids and that heel protectors are used, but these measures were not consistently implemented. The facility did not provide a specific policy related to following physician orders, stating it was standard practice.
Failure to Ensure Proper Catheter Care
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter. The resident was observed multiple times without a leg strap to secure the catheter, and the drainage tubing was often found looped and on the floor. This improper positioning and lack of securement were noted over several days, despite the resident's dependency on staff for personal hygiene and toileting. The resident reported needing to urinate and have a bowel movement, and the incontinence brief appeared tight and stretched, further complicating the situation. The Licensed Practical Nurse confirmed the absence of a securement device and improper positioning of the catheter tubing. The facility's policy on indwelling catheter care emphasizes the importance of inspecting the catheter and tubing to prevent obstructions and ensuring the drainage tube and collection bag are lower than the bladder at all times. The policy also requires the use of a leg band to secure the catheter and prevent tension on the tubing. Despite these guidelines, the facility did not adhere to its own policy, leading to the observed deficiencies. The Director of Nursing acknowledged the issues and indicated that corrective actions would have been taken, but these were not implemented at the time of the observations.
Failure to Provide Timely Assistance and Adequate Staffing
Penalty
Summary
The facility failed to provide timely assistance to meet the needs of residents, as evidenced by multiple instances of delayed response to call lights and insufficient staffing levels. On several occasions, residents reported waiting for an hour or more for assistance after activating their call lights. For example, one resident reported frequent delays of over an hour for assistance, and another resident's call light was observed to be on for nearly 30 minutes before receiving help. These delays were corroborated by observations and interviews with staff and visitors, who noted that staffing levels were often insufficient, particularly on weekends, leading to extended wait times for residents needing assistance. During the survey, multiple call lights were observed to be activated for extended periods without timely response from staff. One resident was found to be visibly diaphoretic and uncomfortable after waiting for nearly 30 minutes for assistance with toileting. Another resident, who required a mechanical lift and two-person assistance to transfer into their wheelchair, reported waiting for over an hour to be helped out of bed. The facility's call station monitor confirmed these extended wait times, with several call lights remaining activated for over 20 minutes. Interviews with staff revealed that the facility was frequently understaffed, with CNAs responsible for managing up to 23 residents each. Staff reported that having three CNAs on duty made the workload more manageable, but this was not consistently the case. A review of the facility's schedule and time punch data confirmed that staffing levels were often inadequate, particularly on weekends, leading to delays in meeting residents' needs. Despite the facility's policy that resident needs should be met within 20 minutes, this standard was not consistently upheld, resulting in significant delays in care.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered per manufacturer recommendations and physician orders for one resident, resulting in a medication error rate of 7.89 percent. During a medication pass observation, an LPN administered cholestyramine along with other medications to a resident, contrary to guidelines that recommend avoiding concurrent administration with other oral medications. Additionally, the resident was prescribed Doptelet, which had not been administered since the beginning of the month, and a Lidoderm patch, which was substituted with a menthol patch without a physician's order at the time of administration. The LPN confirmed the lack of Lidoderm patches in supply and reported the substitution practice to the DON, who later obtained an order to change the prescription to the menthol patch. The DON also addressed the administration schedule for Doptelet, which was to be provided by the resident's family. The facility did not provide a policy or protocol for cholestyramine administration when requested by the surveyors.
Failure to Provide Pureed Diet as Prescribed
Penalty
Summary
The facility failed to ensure that food items were provided in a puree consistency per the diet order for a resident. On multiple occasions, the resident was observed with food items that did not match the prescribed pureed diet, including scrambled eggs, oatmeal, a regular-sized bag of hard pretzels, and a regular cubed piece of frosted cake. These observations were made over two days, and it was noted that the resident had not consumed any of the provided food or liquids. The resident's medical record indicated a diet order for a regular diet with pureed texture and thin liquid consistency, dated earlier in the month. The Director of Nursing and the Registered Dietitian confirmed that the items observed were not part of a pureed diet. The facility's policy on assisting residents with eating emphasized the importance of verifying that the diet served is correct, which was not adhered to in this case.
Failure to Wear Proper PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to wear proper personal protective equipment (PPE) for a resident under Enhanced Barrier Precautions (EBP). On 5/21/2024, a Registered Nurse (RN) was observed entering and exiting the resident's room without wearing the appropriate PPE, despite an EBP sign and cart being present. The resident had a history of chronic urinary tract infections and required assistance with bed mobility and transfers. The RN was unaware of the specific reason for the EBP, indicating a lack of proper adherence to infection control protocols. The Infection Control Preventionist confirmed that all staff had been educated on EBP requirements, yet the deficiency occurred, highlighting a lapse in following the facility's policy on Enhanced Barrier Precautions.
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.
Trusted data from CMS and state health departments
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