The Orchards At Douglas Cove
Inspection history, citations, penalties and survey trends for this long-term care facility in Douglas, Michigan.
- Location
- 243 Wiley Road, Douglas, Michigan 49406
- CMS Provider Number
- 235447
- Inspections on file
- 21
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at The Orchards At Douglas Cove during CMS and state inspections, most recent first.
A resident with atrial fibrillation experienced a rapid, significant weight gain, progressive bilateral leg swelling, severe pain, and loss of functional abilities over more than a week, during which CNAs and family observed edema, increased assistance needs, and the resident crying out in pain. Although weight records and a weight warning note documented a +7.5% gain and ongoing increases, and staff reported swelling, pain, and suspected fluid retention to nursing, no provider assessment occurred and there was no documented physician notification of the weight gain or associated decline. Practitioner Communication forms led only to scheduled acetaminophen, topical diclofenac, and later a PRN opioid, without conveying the full extent of the resident’s weight gain and edema. The PA later confirmed unawareness of the weight gain and swelling, that no provider assessment occurred during this period, and that reliance on written communication sheets rather than direct phone contact contributed to the physician not evaluating the resident before hospitalization.
A resident with AFIB experienced a significant unexplained weight gain, progressive bilateral leg swelling (left greater than right), severe pain, and loss of functional mobility over more than a week, yet nursing staff did not complete timely assessments or notify a provider of the weight gain and change in condition. Multiple CNAs reported increased swelling, pain, and the resident’s need for much more assistance, and the resident and family repeatedly requested provider evaluation. Communication to the provider was limited to written practitioner communication forms that resulted only in scheduled acetaminophen and topical diclofenac, without assessment of the swelling or weight gain. The provider was not made aware of the 9‑pound weight gain or edema, and no provider assessment occurred during this period, culminating in the resident being sent to the ED with bilateral leg pain and swelling and diagnosed with acute CHF, AFIB with RVR, and bilateral lower extremity edema, requiring a three‑day hospitalization.
Two residents did not receive necessary wound care and PICC line management, resulting in missed dressing changes, lack of documentation, and the development of infection. Staff failed to assess, monitor, and treat wounds as ordered, and care plans were incomplete or inaccurate, leading to deficiencies in care for both residents.
A resident with multiple wounds, including pressure ulcers, did not receive wound care as ordered by the physician, with staff failing to apply the correct dressings and omitting required treatments. The care plan was incomplete, missing documentation of all wounds, and weekly skin observations were not performed as required. These deficiencies resulted in inconsistent and inadequate pressure ulcer prevention and treatment.
Two residents did not receive safe and appropriate respiratory care as required. One resident with COPD and sleep apnea experienced delays in physician orders for CPAP and oxygen, lacked a detailed care plan, and was found without supplemental oxygen due to a non-functioning portable tank and kinked tubing. Another resident with heart failure had discrepancies between physician orders and the TAR, unclear oxygen settings, and oxygen tubing that was not changed as scheduled. Staff interviews revealed confusion about proper respiratory care procedures.
A resident with significant cardiac and pulmonary conditions experienced a cardiac arrest, and staff were unable to use the facility's AED because it would not turn on due to a dead battery. The AED was not regularly checked or included in the crash cart checklist, and there was no documentation of functionality checks or battery monitoring. Staff had to rely on a first responder's AED during the emergency.
The facility did not maintain its dishwasher in working order, leading to the use of Styrofoam containers for meal service for over a month. Staff reported delays in obtaining a replacement due to corporate requirements and credit approval issues. A resident expressed dissatisfaction with the quality of meal service during this period.
Three nurse aides continued to provide resident care without proper CNA certification after more than four months of employment. The facility did not have a clear process for tracking and maintaining CNA licensing records, resulting in aides working without required credentials.
The facility failed to provide meals as per the planned menu, leading to resident dissatisfaction. Observations revealed missing items like breadsticks and substitutions such as tuna noodle casserole instead of tuna melt sandwiches. A resident reported not receiving bacon and milk as listed on the menu. The Dietary Manager cited inventory management issues, including burned bacon and milk conservation, as reasons for these discrepancies.
The facility's kitchen had several deficiencies, including inadequate lighting in walk-in coolers, unsanitary utensil storage, improper food cooling, and equipment maintenance issues. These included black debris accumulation, insufficient cooling of apple crisp, ice buildup preventing freezer door closure, and a compromised vacuum breaker on the dish machine.
The facility failed to implement proper infection control precautions for four residents, leading to potential cross-contamination. A resident with conjunctivitis was not properly isolated, as staff entered without PPE. Another resident's enhanced barrier precautions were not updated after catheter removal, causing staff confusion. A third resident had a contact precautions sign but no PPE cart, and a fourth resident lacked proper signage and PPE use during care. These issues indicate a lack of clear communication and adherence to protocols.
A resident with cognitive impairments experienced a breach of dignity when a Maintenance Assistant adjusted her bed without permission while she was asleep. The MA entered the room without knocking and manipulated the bed's position, ignoring the resident's presence. The resident later expressed discomfort with having her bed moved while she was in it. This incident highlights a failure to respect the resident's right to a dignified existence.
A facility failed to report and investigate a suspected misappropriation of a resident's wallet. The resident, who had diabetes, reported a suspicious bank transaction and a missing wallet to an RN, who informed the NHA. The NHA reported it to the local police, but the case was closed due to jurisdiction issues. The NHA did not pursue further investigation as the wallet was found, leaving the misappropriation allegation unresolved.
A facility failed to implement person-centered, non-pharmacological interventions for a resident with anxiety disorder, major depressive disorder, and dementia, who was prescribed Fluoxetine HCl. The care plan included administering medication and monitoring side effects but lacked individualized interventions. The Social Services Director acknowledged the need for a more individualized approach to address the resident's psychosocial needs.
A resident with COPD missed multiple doses of Xifaxan due to a failure in medication reordering. The LPNs did not reorder the medication in time, and the facility lacked backup stock, resulting in missed doses. The ADON confirmed that nurses are responsible for reordering medications, but the policy was not followed.
A resident with anoxic brain damage, quadriplegia, and dysphagia was not assessed quarterly for nutritional needs as required by facility policy. Despite being at nutritional risk and having a care plan for weight loss, the resident's nutritional status was only assessed three times in the past year. The registered dietitian admitted that a missed assessment could lead to unmet nutritional needs and unaddressed weight loss.
The facility failed to ensure that the attending physician reviewed and responded to the consultant pharmacist's monthly medication regimen review recommendations for two residents. For one resident, a recommendation for a gradual dose reduction of Fluoxetine was not addressed, and for another, a recommendation for a fasting lipid panel due to Risperidone use was not acted upon. The facility could not provide evidence of physician responses, and staff confirmed the recommendations were pending.
A facility failed to attempt a required Gradual Dose Reduction (GDR) for an antidepressant medication, Fluoxetine, for a resident with anxiety disorder, major depressive disorder, and dementia. Despite federal guidelines, there was no documented attempt or contraindication for a GDR in the resident's records. Interviews with staff revealed that the Interdisciplinary Team (IDT) was responsible for reviewing medications for GDRs, but the resident had not been seen by a behavioral health service, and the tracking of GDRs was not effectively managed.
A facility failed to document and offer a COVID-19 vaccination to a resident upon admission, as per CDC guidelines and facility policy. The resident, who was severely cognitively impaired, had not been offered the vaccine due to an oversight during the initial nursing assessment. The facility's policy requires offering the updated COVID-19 vaccine unless contraindicated or refused.
Failure to Notify Physician of Resident’s Significant Weight Gain, Edema, and Functional Decline
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in condition for one cognitively intact resident with atrial fibrillation, who experienced a rapid, unexplained weight gain, progressive lower extremity swelling, increased pain, and loss of functional abilities. The resident gained 9 pounds over 32 days, with an additional 4-pound gain documented shortly thereafter, and a weight change note identified a +7.5% significant weight gain with daily weights ordered for monitoring. Despite this documented significant weight gain and the absence of diuretics, there was no evidence that a provider was notified, and no nursing or physician assessments were completed between late January and early February. Over the course of more than a week, the resident reported unresolved pain, swelling in both lower extremities, and a loss of ability to transfer independently, ultimately insisting on going to the emergency room. The resident stated her pain reached 8/10 and that she repeatedly asked to be seen by a physician but was not evaluated. Family reported they requested a provider evaluation and were told the resident would be seen, but this did not occur; they also observed the resident crying from pain. CNAs reported that between early and mid-February the resident’s legs were swollen and painful, socks left indentations, the resident yelled out during care, grabbed her legs, and required increased assistance with transfers and mobility, and they stated they reported these changes and concerns, including suspected fluid retention, to nursing staff. Nursing documentation and interviews showed that although staff were aware of the resident’s new and worsening symptoms, including leg swelling, increased pain, and decreased mobility, the physician was not notified of the significant weight gain and associated changes. Practitioner Communication forms reflected concerns about swollen knees and pain, with provider responses limited to adding scheduled acetaminophen, topical diclofenac gel, and later a PRN opioid, but there was no indication the provider was informed of the 9‑pound weight gain, bilateral lower extremity swelling, or functional decline. The PA confirmed she was unaware of the resident’s weight gain and leg swelling, that the resident was not assessed by a provider during the relevant period, and that communication sheets placed in provider mailboxes were often overlooked, despite providers being available by telephone 24/7. This sequence of events resulted in the physician not evaluating the resident when she experienced a significant change in condition and was subsequently hospitalized.
Failure to Recognize and Act on Resident’s Change in Condition Leading to Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to promptly identify and assess a significant change in condition for a cognitively intact resident with atrial fibrillation, resulting in unmanaged pain, swelling, decreased functional ability, and hospitalization. The resident had a history of unspecified atrial fibrillation and was care planned for potential pain related to AFIB, with interventions to administer analgesics per orders and evaluate pain interventions. However, the care plan did not include any focus, goals, or interventions related to monitoring swelling, daily weights, or use of a cardiac monitor. A Minimum Data Set (MDS) dated 1/23/26 showed the resident was largely independent or required only supervision for bed mobility and transfers, but a subsequent MDS dated 2/13/26, after a hospitalization, showed a decline to requiring maximal assistance for transfers and bed mobility. Over the period from late January to early February, the resident experienced a 9‑pound weight gain between 12/30/25 and 2/1/26, with an additional 4‑pound gain documented on 2/6/26. A nutrition note on 2/4/26 identified the weight increase and placed the resident on daily weights for seven days, and a weight change note on 2/5/26 documented a significant 7.5% weight gain with no diuretics ordered. The DON later confirmed that the physician was not notified of this weight gain and that the resident was not evaluated by a provider between 2/1/26 and 2/10/26. Review of assessments and progress notes showed no nursing or physician assessments between 1/27/26 and 2/8/26 and no documentation that a provider was contacted regarding the unexplained weight gain during 2/1–2/10/26. During the first part of February, multiple CNAs observed and reported changes in the resident’s condition, including bilateral leg swelling (left greater than right), increased pain, yelling out with movement, and a need for significantly more physical assistance with transfers and mobility. CNAs reported that the resident, who typically tried to remain independent, now required help lifting her legs into bed and for all transfers, and they noted sock indentations and suspected fluid retention. The resident and a family member reported that for more than a week prior to hospitalization, the resident had unresolved pain and swelling in both lower extremities, decreased mobility, and loss of ability to transfer independently, and that they requested provider evaluation. A practitioner communication form dated 2/2/26 documented a concern about swollen knees, with a provider response on 2/3/26 ordering scheduled acetaminophen and diclofenac gel; a second communication form dated 2/9/26 documented ongoing pain, especially in the lower extremities, and family requests for different pain medications, with a provider response dated 2/17/26 adding an opioid PRN. The PA later stated she was aware of leg pain but not of swelling or the 9‑pound weight gain, and confirmed the resident was not assessed by a provider between 2/1/26 and 2/10/26. On 2/10/26, the resident went to the emergency department with bilateral leg pain and swelling, was found to have bilateral pitting edema and presumed new congestive heart failure with atrial fibrillation with rapid ventricular response, and was hospitalized for three days. Following the hospitalization, discharge instructions documented diagnoses of acute CHF, AFIB with RVR, and bilateral lower extremity edema, with orders for daily weights and notification of the physician for specified weight gains, and a cardiac monitor placed at discharge. Upon return, the resident required maximal assistance for transfers and bed mobility compared to her prior status. The DON and nursing staff acknowledged that the significant unexplained weight gain, leg swelling, increased pain, and functional decline should have prompted further medical assessment and provider notification, and that the communication method used (written communication sheets placed in a mailbox) was ineffective and contrary to prior education to call providers by phone. The failure to recognize and act on the resident’s change in condition, including not notifying the physician of significant weight gain and progressive symptoms, led to unmanaged pain, swelling, decreased functional ability, and the subsequent hospitalization.
Failure to Provide Adequate Wound and PICC Line Care
Penalty
Summary
The facility failed to provide necessary care and services for two residents requiring specialized wound and intravenous (IV) care. One resident was admitted with diagnoses including infective endocarditis and a surgical wound on the right foot, requiring daily wound dressing changes and long-term IV antibiotics via a PICC line. Upon review, it was found that the resident did not receive appropriate wound care or PICC line management following admission. The wound dressing applied at the hospital remained unchanged for several days, and the PICC line was observed without a protective cap, increasing the risk of infection. Orders for wound care and PICC line dressing changes were either not entered or entered incorrectly into the facility’s records, resulting in missed treatments and lack of monitoring. Nursing staff failed to document the condition of the wound or the PICC line, and weekly skin assessments did not reflect the resident’s actual needs or current conditions. Another resident with diabetes, dementia, and multiple wounds, including a diabetic ulcer and pressure ulcers, was also not provided with adequate wound care. The resident was observed without dressings on several wounds, and a wound on the bottom of the left foot was not assessed, monitored, or treated by facility staff. This wound was not documented in the facility’s records or skin assessments, despite being noted by an outside nurse from a community day center. The lack of documentation and treatment led to the development of a wound infection, as confirmed by subsequent medical notes and the need for antibiotic therapy. Interviews with facility staff, including the DON and LPNs, revealed a lack of awareness and communication regarding the residents’ wound care needs and PICC line management. Staff relied on incomplete or incorrect documentation, resulting in missed treatments and failure to identify or address new and existing wounds. The facility’s care plans and treatment administration records were not resident-centered and did not include specific interventions or monitoring for the residents’ conditions, directly contributing to the deficiencies in care.
Failure to Provide Pressure Ulcer Care per Physician Orders and Protocols
Penalty
Summary
The facility failed to provide quality care and treatment for pressure ulcers in accordance with professional standards for one resident. The resident, who had a history of bilateral below-knee amputations and spinal fractures, was observed with multiple wounds, including a large dressing on the sacrum that was not fully intact, an open and actively bleeding wound on the right buttock without a dressing, and a dressing on the right knee. During wound care, it was noted that the prescribed calcium alginate with silver was not applied to the right knee or sacrum wounds, and the dressings used did not match physician orders. The right buttock wound was not covered with the required hydrocolloid dressing, and the LPN providing care was unaware of the specific dressing requirements outlined in the treatment orders. Further review revealed that the resident's care plan did not include all current wounds, specifically omitting the stage 2 pressure ulcers on the coccyx and right knee. Weekly skin observations and documentation were also lacking, with no entries for the past three weeks. The CNA staff relied on incomplete care plans for direct care, and the treatment administration record indicated inconsistencies between ordered and provided wound care. These actions and omissions resulted in a failure to follow physician orders and facility protocols for pressure ulcer prevention and treatment.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care for two residents, resulting in deficiencies related to the administration and monitoring of oxygen and CPAP therapy. For one resident with chronic obstructive pulmonary disease and obstructive sleep apnea, physician orders for CPAP and continuous oxygen therapy were not entered until several days after admission. The care plan did not specify the type or amount of oxygen, nor did it include a plan for CPAP use. Staff interviews revealed that the resident required constant supplemental oxygen, and an incident occurred where the resident arrived at a community day center short of breath with a blood oxygen level of 80% due to a portable oxygen tank not being turned on and kinked tubing, resulting in the resident being without supplemental oxygen for at least 25 minutes. For another resident with heart failure, there was a discrepancy between the physician's order for oxygen and the transcription of that order to the treatment administration record (TAR), leading to uncertainty among staff regarding the correct oxygen setting. Additionally, the oxygen tubing was not changed according to the schedule indicated in the TAR, as the tubing observed in the resident's room was last changed over a week prior, despite documentation stating otherwise. Staff interviews confirmed a lack of clarity regarding the resident's oxygen settings and the required frequency for changing oxygen tubing.
Failure to Maintain AED Functionality During Cardiac Emergency
Penalty
Summary
The facility failed to ensure the regular checking and maintenance of its automatic external defibrillator (AED), resulting in the device being inoperable during a critical cardiac arrest emergency involving a female resident with a history of heart disease, pulmonary embolism, and mediastinal cancer. When the resident was found unresponsive and a Code Blue was called, staff attempted to use the facility's AED, but it would not turn on due to a dead battery. There was no backup battery available at the time, and the staff had to rely on an AED provided by a first responder. Interviews and record reviews revealed that the AED was not included in the routine crash cart checklist, and there was no documentation of regular functionality checks or battery monitoring. The Director of Nursing and Maintenance Director both confirmed the absence of a process or evidence for AED checks, and the AED Inspection Log showed the last inspection was not recent. The lack of established procedures and documentation for AED maintenance directly led to the device's failure during the emergency.
Failure to Maintain Operable Dishwasher Resulting in Prolonged Use of Disposable Meal Containers
Penalty
Summary
The facility failed to maintain its dishwasher in an operable condition, resulting in the use of Styrofoam containers for meal service to all residents. Staff interviews revealed that the dishwasher had been out of service for over 30 days, with the Dietary Manager noting the initial order of Styrofoam containers in mid-February. The previous Maintenance Director confirmed that the dishwasher was too old to repair cost-effectively and that parts were unavailable. Documentation showed that the facility began seeking quotes for repair or replacement in late January, but delays occurred due to the corporate requirement to obtain three quotes and issues with credit approval for leasing a new dishwasher. During this period, residents were served meals in Styrofoam containers, with at least one resident expressing dissatisfaction with the prolonged use of disposable containers and the resulting cold or lukewarm food. Staff interviews indicated uncertainty and delays in the procurement process, with the Administrator and Dietary Manager both referencing ongoing efforts to secure a replacement dishwasher but facing obstacles related to corporate approval and financing. There was no mention of a COVID outbreak necessitating the use of disposable containers.
Failure to Ensure CNA Certification for Nurse Aides Within Required Timeframe
Penalty
Summary
The facility failed to ensure that three nurse aides employed for more than four months were properly certified before continuing to provide resident care. A review of the Nurse Aide Public Registry revealed that three nurse aides did not have a Certified Nursing Assistant (CNA) license on file. One aide had not paid the required fee to have her license placed in the licensing system, and the facility had not received a copy of her CNA license. Another aide, after completing the facility-paid nursing assistant class, failed the certification test but continued to work full-time providing resident care. The third aide transitioned from assisted living to long-term care, attended CNA training paid for by the facility, but did not have a CNA license on record. Interviews with human resources and administrative staff indicated a lack of clarity regarding responsibility for tracking and maintaining CNA licensing records. The scheduler was responsible for enrolling staff in CNA training, but there was uncertainty about who ensured that licensing requirements were met and documented. This lack of oversight resulted in nurse aides working beyond the four-month training period without proper certification, as required.
Failure to Adhere to Planned Menu
Penalty
Summary
The facility failed to ensure that residents received meals as outlined on the planned and posted menu, leading to potential dissatisfaction and frustration among residents. On 7/16/24, during a dining observation, it was noted that meal trays did not contain breadsticks as specified on the menu. The Dietary Manager (DM) confirmed that breadsticks were not served because they were not pulled from the freezer. Additionally, a planned tuna melt sandwich for supper was substituted with tuna noodle casserole without updating the posted menu. Resident #39 reported not receiving bacon for breakfast and milk for lunch, which were both listed on the menu. The DM explained that the bacon was burned the previous day, resulting in a shortage, and milk was conserved for breakfast due to purchasing challenges. Resident #16 also reported that the kitchen occasionally ran out of items, leading to deviations from the menu. The Resident Council Meeting Minutes from 7/12/24 indicated that residents felt the food served was different from the menu. The DM, new to the position, acknowledged difficulties in managing inventory, particularly with milk, and instructed staff to conserve milk for breakfast if supplies were low. These issues highlight the facility's failure to adhere to the planned menu, affecting the residents' meal satisfaction and nutritional intake.
Sanitation and Cooling Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially spread foodborne illness to all residents consuming food from the kitchen. During an initial tour, it was observed that the walk-in coolers were inadequately lit, making it difficult to see the heavy accumulation of black debris on the floor perimeter and around the storage shelves. The clean utensil drawers under the preparation table contained excess crumb debris, and the parchment paper used as a barrier was old and discolored. The Dietary Manager was unaware of when the paper was last changed. Additionally, the light intensity in the walk-in cooler and freezer was below the required levels, with readings between 0.5-2.1 foot candles at the back of the units. The facility also failed to properly cool food, as evidenced by a gallon container of apple crisp stored in the walk-in cooler with heavy condensation and a temperature of 95.5°F. Upon a return visit, the apple crisp had not cooled adequately, with a temperature of 69.8°F, failing to meet the required cooling standards. Other issues included ice accumulation impeding the walk-in freezer door's ability to close, large rips and tears in the gasket seal of a cooler door, and a missing top cap on the atmospheric vacuum breaker of the dish machine, compromising its integrity. These deficiencies indicate a lack of adherence to the 2017 FDA Food Code requirements for equipment cleanliness, cooling methods, and facility maintenance.
Inadequate Implementation of Infection Control Precautions
Penalty
Summary
The facility failed to properly implement enhanced barrier and contact isolation precautions and the use of personal protective equipment (PPE) for four residents, leading to potential cross-contamination and spread of infection. Resident #33, who was cognitively intact and had an eye infection, was placed on contact isolation precautions. However, during an observation, the Activity Director entered the resident's room without wearing PPE, handled the resident's electronic device, and only used hand sanitizer upon exiting. This was contrary to the facility's policy, which required staff to wear a gown, gloves, and mask when entering the room and handling the resident's belongings. Resident #8 was initially placed on enhanced barrier precautions due to having a catheter, which was later removed. Despite the catheter's removal, there was confusion among the staff regarding the continuation of these precautions. The facility's process for initiating and discontinuing enhanced barrier precautions was unclear, leading to inconsistent practices. The resident's electronic health record (EHR) lacked orders for these precautions, and staff were unsure if they were still required to follow them. Resident #9 was observed to have a contact precautions sign on their door, but there was no PPE cart available. Staff were uncertain about the resident's current precaution status, as there were no orders in the EHR for initiation or discontinuation. Similarly, Resident #41 had a PPE cart in their room but lacked a sign indicating the type of precautions required. The resident's EHR was missing an order for enhanced barrier precautions, and staff were observed not wearing appropriate PPE during medication administration. These deficiencies highlight a lack of clear communication and adherence to infection control protocols within the facility.
Failure to Maintain Resident Dignity During Bed Maintenance
Penalty
Summary
The facility failed to maintain the dignity of Resident #29 by conducting maintenance work on her bed while she was asleep, without her permission. The Maintenance Assistant (MA) entered the resident's room without knocking and adjusted the bed's position multiple times while the resident was in it, without acknowledging her presence. This action was observed by a Registered Nurse (RN), who laughed with the MA about the situation, indicating a lack of respect for the resident's dignity. Resident #29, who has diagnoses including major depressive disorder, Alzheimer's disease, and cognitive communication deficit, expressed that she did not like having her bed moved while she was in it. The MA admitted to performing maintenance on beds with residents in them, especially if they were cognitively impaired and unlikely to voice concerns. This behavior disregarded the resident's right to a dignified existence and self-determination, potentially leading to feelings of frustration, fear, and dehumanization.
Failure to Report and Investigate Suspected Misappropriation
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act. This deficiency involved a resident who was admitted with a diagnosis of diabetes. The resident received a notification from their bank about a suspicious purchase, leading to the discovery that their wallet was missing. The resident reported the missing wallet to a registered nurse, who then informed the Nursing Home Administrator (NHA). The NHA reported the incident to the local police department. However, the local police closed the case because the incident occurred in a different county. The NHA did not contact the appropriate police department to open a new investigation, as the wallet was found, and thus, the allegation of misappropriation was not thoroughly investigated.
Failure to Implement Person-Centered Interventions for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to identify and implement person-centered, non-pharmacological interventions for a resident receiving psychotropic medication. Resident #17, a female with diagnoses including anxiety disorder, major depressive disorder, and dementia, was prescribed Fluoxetine HCl for depression. The care plan for Resident #17 included administering antidepressant medications as ordered and monitoring for side effects and effectiveness every shift. However, the care plan lacked individualized, non-pharmacological interventions to address the resident's depression. During an interview, the Social Services Director (SSD) acknowledged responsibility for developing care plans for residents on psychotropic medications. The SSD admitted that the care plan for Resident #17 needed to be more individualized with person-centered, non-pharmacological approaches. The SSD noted that interventions could be added or revised as more information about the resident was learned, indicating a deficiency in the current care plan's ability to meet the resident's psychosocial needs.
Medication Reordering Failure
Penalty
Summary
The facility failed to ensure that Resident #245 received ordered medications as scheduled, which resulted in the potential for worsening health conditions. Resident #245, who was admitted with chronic obstructive pulmonary disease (COPD), had an order for Xifaxan Oral Tablet 550 MG to be administered twice daily for diarrhea. However, the medication was not available, and the resident missed two doses on 7/16/24 and one dose on 7/17/24. Licensed Practical Nurse (LPN) N reported that the medication had not been re-ordered and was not available in the facility's backup stock, requiring contact with the pharmacy for delivery. The Assistant Director of Nursing (ADON) D and LPN L confirmed that nurses were responsible for reordering medications before they ran out and contacting the pharmacy if a medication was missing. Despite this, LPN L did not contact the pharmacy or physician when the medication was discovered missing on 7/16/24. The facility's Medication Reordering Policy, last revised in 12/2023, outlines that medications should be reordered when six or fewer doses remain, but this procedure was not followed, leading to the deficiency.
Failure to Conduct Timely Nutritional Assessments
Penalty
Summary
The facility failed to ensure timely and consistent assessment, monitoring, or reassessment of a resident's nutritional and hydration status, leading to a deficiency in nutritional care and services. The resident, who was admitted with diagnoses including anoxic brain damage, quadriplegia, and dysphagia, was identified as being at nutritional risk. Despite being cognitively intact and on a mechanically altered diet, the resident's care plan noted unplanned weight loss related to variable meal intake and supplement refusals. The care plan included interventions such as monitoring weight loss, food intake, and having a registered dietitian evaluate and recommend diet changes. However, the facility's policy required a comprehensive nutritional assessment by a dietitian within 72 hours of admission, annually, and upon significant change in condition, with follow-up assessments as needed. The resident's nutritional needs were assessed only three times in the last twelve months, missing the quarterly assessment required by the facility's policy. The registered dietitian acknowledged that an assessment should have been completed in December 2023 but was not, resulting in the potential for unmet nutritional needs and unaddressed weight loss, which could worsen the resident's overall health.
Failure to Address Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician reviewed and responded to the consultant pharmacist's monthly medication regimen review (MRR) irregularity report recommendations for two residents. This deficiency was identified during a survey, where it was found that the registered pharmacist's recommendations were not addressed, leading to the potential for negative medication side effects. The facility's policy requires that any irregularities noted by the pharmacist during the MRR must be documented and acted upon by the attending physician, with the physician's response recorded in the resident's medical record. For Resident #17, the pharmacist recommended a gradual dose reduction (GDR) for the medication Fluoxetine, as per federal guidelines. However, the physician's response section on the pharmacy recommendation report was left blank, indicating that the recommendation was not reviewed or acted upon. Despite multiple requests from the surveyor, the facility was unable to provide evidence of the physician's response to the recommendation, and the consultant pharmacist confirmed that the recommendation was still pending. Similarly, for Resident #8, the pharmacist recommended obtaining a fasting lipid panel due to the use of the antipsychotic medication Risperidone, which may induce hyperlipidemia. The physician's response to this recommendation was also incomplete, and the facility could not provide evidence that the recommendation had been reviewed or acted upon. Interviews with facility staff, including the Assistant Director of Nursing and a Nurse Practitioner, confirmed that there was no record of the physician's response or any orders for the recommended lab test.
Failure to Attempt Gradual Dose Reduction for Antidepressant Medication
Penalty
Summary
The facility failed to attempt a required Gradual Dose Reduction (GDR) of an antidepressant medication, specifically Fluoxetine, for a resident diagnosed with anxiety disorder, major depressive disorder, and dementia. The resident was receiving two different dosages of Fluoxetine, 10 mg and 20 mg, daily for depression. Despite federal guidelines requiring an attempt at a GDR twice per year for the first year, there was no documented attempt or contraindication for a GDR in the resident's medical records. This oversight was confirmed during interviews with the Social Services Director and the Assistant Director of Nursing, who both acknowledged the absence of a GDR attempt for the resident. The Social Services Director indicated that the Interdisciplinary Team (IDT) typically reviewed medications for GDRs during Risk Meetings, and it was usually the responsibility of the contracted behavioral health service or the resident's physician to make GDR recommendations. However, the resident had not been seen by a contracted behavioral health service. The Assistant Director of Nursing also confirmed that the IDT was responsible for tracking GDRs, but she had not been involved in this process. The Nursing Home Administrator stated that nursing staff, including the Director of Nursing, were responsible for tracking GDRs, but the Director of Nursing was unavailable for comment during the survey. The lack of documentation for a GDR or a contraindication highlights a gap in the facility's medication management process for this resident.
Failure to Document and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that a resident's medical records included documentation of education, offering, and timely receipt of the COVID-19 immunization as recommended by the CDC. This deficiency was identified for one resident, who was not offered the COVID-19 immunization upon admission to the facility, as per the facility's policy and CDC guidelines. The resident, who was severely cognitively impaired with a BIMS score of 00/15, had last received the COVID-19 vaccine in June 2022. During an interview, the Assistant Director of Nursing/Infection Prevention acknowledged that the resident should have been offered the COVID-19 vaccination upon admission and annually thereafter. The failure to offer the vaccine was attributed to a mistake during the resident's initial nursing assessment. The facility's policy, dated September 2023, states that residents should receive an additional dose of the updated COVID-19 vaccine at least four months after the previous dose unless medically contraindicated, already immunized, or if the resident refuses.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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