The Orchards At Niles
Inspection history, citations, penalties and survey trends for this long-term care facility in Niles, Michigan.
- Location
- 1333 Wells St, Niles, Michigan 49120
- CMS Provider Number
- 235598
- Inspections on file
- 29
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at The Orchards At Niles during CMS and state inspections, most recent first.
Licensed staff did not follow professional standards or the facility’s Acute Change in Condition policy when a resident with dementia and other cognitive and physical impairments became confused and restless, was found to have an O2 saturation of 88% (improving to 93% on 2L O2), and had blood in the stool. The nurse documented the event and placed a note in the physician log but did not obtain a complete set of vitals or directly notify a provider. Review of records showed no provider follow-up for these concerns, and interviews with an LPN, the unit manager, and the DON confirmed that facility protocols required full assessment and immediate provider notification for such changes, including possible GI bleed.
Two residents with severe cognitive impairments were involved in a physical altercation, which was witnessed by a staff member and internally reported to nursing and administrative staff. Although the incident was documented and discussed by the interdisciplinary team, the required report to the State Agency was not submitted, resulting in an incomplete investigation and failure to meet reporting requirements.
A resident with vascular dementia and hand stiffness was not wearing a recommended left resting hand splint, as observed multiple times. Despite therapy recommendations and staff training, there was no physician order or documentation of the resident's refusal to wear the splint. Interviews with staff revealed a lack of awareness and documentation regarding the splint's application, indicating a breakdown in communication and processes within the facility.
A resident with a history of urinary retention and recurrent UTIs was hospitalized due to a severe UTI and sepsis after the facility failed to provide adequate catheter care and monitoring. Despite signs of infection and abnormal urinalysis results, timely action was not taken. The facility lacked proper documentation and communication regarding the resident's condition and test results, leading to a delay in treatment and subsequent hospitalization.
A resident with vascular dementia and coordination issues was not provided with a divided plate as ordered by the physician, which was necessary for self-feeding. The resident was observed eating from a regular flat plate, contrary to the tray ticket instructions. The registered dietitian confirmed the importance of the divided plate for the resident's ability to eat independently.
A facility failed to maintain accurate medical records and monitor a resident's condition, leading to a lack of documentation for catheter care, test results, and vital signs related to an impending UTI. Despite symptoms like cloudy urine and decreased appetite, there were gaps in documentation and no orders for catheter care. Staff interviews revealed that abnormal urinalysis results were not promptly addressed, and CNA tasks showed no documentation of catheter care for 30 days. The resident was eventually sent to the ER.
The facility did not hold Quality Assessment and Assurance (QAA) meetings quarterly as required, and the Medical Director missed two meetings. There was a gap in meetings from January to August, with the Nursing Home Administrator meeting department heads individually instead. The QAPI policy mandates quarterly meetings with specific members, including the DON and Medical Director.
The facility failed to ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control. The DON, responsible for the infection control program, did not complete the post-test of the CDC IP certification training, resulting in a lack of certification. The UM assisting in the program also lacked certification. The NHA was unaware of these deficiencies.
The facility failed to provide annual abuse prevention training for all staff, affecting 33 out of 104 employees. This deficiency was identified through interviews and record reviews, revealing that staff were often pulled to work on the floor, leaving insufficient time for training. Despite measures to track and remind staff of training requirements, the facility's records showed a significant number of staff had not completed the necessary training.
The facility failed to provide consistent, meaningful, and person-centered activities for residents in the dementia care unit. Despite having an activity calendar, scheduled activities were not conducted, leaving residents idle or asleep without engagement. Residents with specific interests, such as music, crafts, and socializing, were not observed participating in these activities. Documentation showed a lack of recorded group activities and minimal one-on-one interactions. Staffing challenges and lack of training contributed to the deficiency.
The facility failed to employ a dietary manager with appropriate training and certifications, leading to potential food service sanitation failures and foodborne illness risks. The kitchen has been without a manager for over a month, and the Registered Dietitian visits infrequently without monitoring the kitchen. The NHA is aware of the situation but is unable to provide adequate oversight due to other responsibilities.
The facility failed to properly label and date foods in the kitchen, risking foodborne illness for residents. Observations included unlabeled and undated cheese, milk, shredded pork, cranberry concentrate, bread crumbs, thickener, sugar, and bacon bits, violating the 2017 FDA Food Code.
The facility failed to provide behavioral health care training for 104 staff members, with 78 not receiving annual abuse prevention training. CNA V reported time constraints due to work duties, while Receptionist EEE tracked training completion and sent reminders. Administrator A confirmed training was completed as needed, but evidence of compliance was lacking.
A resident with osteomyelitis and end-stage renal disease requested a hospital transfer due to severe pain, but the Medical Director denied the request, citing non-emergency and transfer management concerns. The resident felt angry and frustrated, and despite the Medical Director's disapproval, the resident was eventually sent to the ER. This incident reflects a failure to uphold the resident's dignity and self-determination.
A resident with osteomyelitis and end-stage renal disease was moved to a different room without proper notification, despite initially refusing the change. The facility failed to provide written notice or documentation of the resident's agreement to the move, as required by policy. Interviews revealed inconsistencies in the facility's handling of the situation, leading to the deficiency.
The facility failed to maintain accurate advanced directive information for two residents, leading to discrepancies in their code status documentation. One resident's electronic medical record indicated a Full Code status, while a physical document showed a DNR status. Another resident's code status was updated by the guardian to allow CPR, but this change was not reflected in the medical record. Staff were unaware of these discrepancies, resulting in potential misalignment with residents' medical care preferences.
A resident with dementia and Alzheimer's was subjected to physical abuse by a CNA during a shower, where the CNA covered her mouth and sprayed water in her face to silence her. This incident, which increased the resident's agitation, was witnessed by another CNA who reported the behavior to management. The offending CNA had a history of similar actions, but these were not reported until this incident. The facility had not provided abuse-related education in recent staff training.
A resident, who was cognitively intact, reported a theft of money from their room and informed the police and facility staff. The NHA reported the incident to the State Agency but failed to submit the final investigation due to going on vacation, and no other management team member completed the submission within the required timeframe.
The facility failed to complete PASARR and OBRA Level II documentation for two residents. One resident lacked an Annual Resident Review, and the social worker was unsure of the responsible party for completion. Another resident, with dementia and borderline personality disorder, did not have a Level II assessment or exemption letter, as the original PASRR was not submitted by the referring facility.
The facility failed to provide adequate ADL care for three residents, leading to poor personal hygiene and grooming. A resident with dementia was observed with unkempt facial hair, another with Alzheimer's had long facial hairs, and a male resident with a fractured humerus was in a state of poor hygiene. Care plans requiring assistance were not followed, and staff faced challenges accessing necessary grooming supplies.
A resident at risk for pressure ulcers due to impaired mobility and a history of wounds did not receive necessary preventative care. Despite orders for a protective dressing, the resident missed multiple treatment opportunities and was left sitting for extended periods without repositioning. Staff interviews revealed a lack of awareness and adherence to treatment plans, and the resident's risk assessment was outdated.
A resident with dementia and mobility issues was transferred by a CNA without using a gait belt, contrary to the care plan requiring two-person assistance and a gait belt. The CNA, unfamiliar with the resident's needs, believed a one-person transfer was sufficient. Other staff confirmed the correct protocol, and the DON emphasized the necessity of using a gait belt for transfers.
A facility failed to develop a person-centered care plan for a resident with dementia, anxiety, and depression, focusing mainly on medication without addressing her need for meaningful activities. The resident frequently exhibited distressing behaviors, which staff struggled to manage due to inconsistent documentation and lack of training. The facility did not provide adequate dementia care training for 39 out of 104 employees, potentially compromising the resident's well-being.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in medication administration and treatment documentation. A resident received the wrong insulin without updating the physician's order, another had nebulizer treatments inaccurately documented, and a third had incomplete wound care records.
The facility failed to ensure proper use of PPE for two residents under enhanced barrier precautions due to open wounds. Staff, including CNAs and a hospice nurse, were observed not wearing gowns during high-contact care activities, despite signage indicating EBP requirements. Interviews revealed inconsistencies in understanding and implementing EBP protocols, with some staff unaware of the need for PPE or misunderstanding which residents required it.
The facility failed to offer recommended Pneumococcal vaccines to eligible residents, impacting two residents reviewed for immunizations. One resident, over 65 and admitted in early 2024, had prior vaccinations but was eligible for additional doses, with no documentation of education or consent. Another resident had a historical dose but was also eligible for further vaccination, with no record of being educated or offered the vaccine. The DON acknowledged the oversight, indicating a lack of action in ordering vaccines and documenting processes.
The facility did not maintain documentation of staff COVID-19 vaccinations. The DON stated that while the vaccine was available, there was no record of it being offered or declined by staff. The NHA was unaware of the need to document staff education, vaccine offering, or vaccination status.
The facility failed to conduct annual performance evaluations for CNAs, as revealed by personnel file reviews and staff interviews. CNAs, including one who had been employed for four years, reported not receiving evaluations. Staff interviews indicated confusion over responsibility for generating and completing evaluations, with the nursing department ultimately responsible but not fulfilling this duty.
The facility was cited for failing to maintain a clean and sanitary environment, with observations of dirt, debris, and dried liquids in resident rooms and hallways. Staff interviews revealed inconsistent cleaning practices, with mopping only half of the hallway at a time and deep cleaning conducted monthly. Cobwebs were also noted in a resident's room, indicating a lack of regular cleaning.
The facility failed to maintain safe and comfortable temperatures in resident rooms, affecting two residents. One resident's room was hot and stuffy, with no AC unit, despite a care plan indicating a need for hydration due to malnutrition. Another resident reported discomfort due to heat, as his room lacked an AC unit and fan. Temperature logs showed high temperatures, and staff were inadequately trained in temperature checks. Complaints about the heat were noted, but the facility's response was insufficient.
The facility failed to implement enhanced barrier precautions (EBP) for two residents, leading to potential infection spread. A resident with a pressure ulcer and another with a diabetic ulcer were not provided care with the required PPE, despite EBP signs. Staff interviews confirmed non-compliance with EBP protocols, resulting in a deficiency citation.
The facility failed to maintain resident dignity and timely care for two residents. One resident was found with food debris on her bed after meals, contrary to staff practices of ensuring cleanliness. Another resident reported dissatisfaction with night CNAs, who allegedly made rude comments and delayed assistance, stating they were only required to change her every two hours. Despite documented complaints, there was no indication of verbal abuse being reported to management.
A resident with cerebral palsy, epilepsy, and Rett's syndrome did not receive consistent care plan interventions, leading to inadequate protection against skin breakdown and contractures. Observations showed missing protective equipment and improper wheelchair positioning, while staff interviews revealed gaps in documentation and follow-through on care plans.
Three residents in an LTC facility were not provided with adequate personal hygiene care, resulting in unmet needs. A resident with Alzheimer's and limited mobility had plaque buildup and decaying teeth, while another with limited mobility had unbrushed teeth and disheveled hair. A third resident, dependent on staff due to multiple conditions, was observed with greasy hair and plaque buildup. Missed showers and inconsistent documentation of refusals contributed to the deficiency.
A resident with severe malnutrition and muscle wasting was not provided sufficient hydration, as her water was often left untouched and out of reach. Despite care plan interventions, her fluid intake was consistently below her needs, and staff did not adhere to the facility's hydration policy, leading to potential dehydration.
The facility failed to develop, implement, and update person-centered care plans for three residents, resulting in potential unmet care needs and risk of injury. One resident's allergies were not documented, another's care plan lacked specific information about mobility and visual impairment, and a third resident's care plan was outdated regarding transfer needs.
The facility failed to ensure safe transfers by not using gait belts during manual transfers and not having two staff members present during mechanical lift transfers. A CNA transferred a resident with Alzheimer's disease without a gait belt, and another CNA transferred a resident with cerebral infarction using a mechanical lift alone, contrary to facility policy.
The facility failed to ensure proper pre and post dialysis treatment assessment and monitoring communication between the facility and the dialysis provider for two residents, resulting in a potential disruption in the continuity of care. Both residents lacked physician orders for dialysis treatments, and staff interviews confirmed the absence of necessary communication forms.
The facility failed to maintain accurate medical records for a resident, resulting in inconsistent documentation of allergies. Staff members had conflicting interpretations of hospital discharge paperwork, leading to the incorrect recording of 'no known allergies' despite the resident having documented allergies to multiple medications.
The facility failed to provide a dignified dining experience for several residents, resulting in feelings of disappointment. Multiple residents were observed with their lunch trays but without staff assistance, leading to visible worry and disappointment. The DON acknowledged the dignity concern and the facility's policy emphasizes treating residents with respect.
A resident with multiple medical conditions experienced a delayed discharge to an assisted living facility due to the LTC facility's failure to promptly send a necessary referral, resulting in additional private pay charges. The Social Work Director was on maternity leave, and the family had to contact the Ombudsman to resolve the issue.
The facility failed to accurately assess a resident with multiple diagnoses, including diabetes and a tibial fracture, upon admission. The skin assessment did not document existing blisters, redness, or a wound on the right great toe, despite these conditions being noted by the referring hospital. The DON confirmed the omissions, indicating a lapse in the assessment process.
A facility failed to establish a baseline care plan within 48 hours for a resident admitted with multiple significant diagnoses, including diabetes and a right tibia fracture. The resident's baseline care plan was not completed until several days after admission, resulting in a lack of person-centered ADL care instructions for the nursing staff.
The facility failed to implement a comprehensive care plan for a resident with multiple complex medical conditions, including cerebral palsy and Rett's syndrome. The care plan indicated the use of palm protectors, but there was no order for hand paddles for contractures. Observations and staff interviews revealed inconsistencies in care plan implementation and documentation, resulting in a lack of service for the resident's well-being.
A facility failed to follow professional standards of nursing practice for a resident with multiple health conditions, including a fractured tibia and a wound on the right great toe. There were no orders for catheter care, missed dressing changes, and a delay in follow-up care with an orthopedic surgeon due to lack of transportation and coordination.
The facility failed to provide adequate ADL care for two residents, resulting in neglect of personal hygiene and dignity. One resident was not assisted with bathing and toileting, while another had matted hair and facial hair unattended. Documentation and follow-up on refusals were inconsistent, highlighting systemic issues in care practices.
The facility failed to ensure proper assessment and treatment for two residents, resulting in unaddressed pain, swelling, and elevated blood glucose levels. One resident's foot pain and swelling were not adequately assessed or treated, leading to a possible pressure ulcer. Another resident did not receive proper diabetic monitoring, with no documentation of blood sugar levels or lab tests for three months.
The facility failed to accurately assess, monitor, and treat pressure ulcers for two residents, leading to inconsistencies in wound care and documentation. One resident reported missed dressing changes, and another had multiple missed dressing changes with no proper documentation or follow-up.
A resident with muscle weakness and type 2 diabetes experienced unresolved pain and untreated high blood glucose levels due to the facility's failure to complete a medical evaluation, review treatment appropriateness, and implement orders. Despite reporting foot pain and swelling, and having elevated blood glucose levels, the resident's concerns were not adequately addressed by the physician or nursing staff.
A facility failed to ensure timely physician visits for a resident with multiple diagnoses, resulting in the potential for unmet medical needs. The resident did not receive a required physician visit in December, as confirmed by staff interviews and medical record reviews.
Failure to Notify Provider and Fully Assess Resident With Acute Change in Condition
Penalty
Summary
Licensed staff failed to follow professional standards of practice and the facility’s Acute Change in Condition policy when a resident experienced an acute change in condition. The resident, a female with dementia, mild cognitive impairment, dysphagia, cognitive communication deficit, muscle weakness, lack of coordination, and need for assistance with personal care, was documented in a nurse’s note at 2:15 AM as being confused and restless, with an oxygen saturation of 88% that improved to 93% after application of 2L O2, and with blood noted in her stool. Despite these findings, there was no documentation in the medical record of a full set of vital signs (blood pressure, temperature, pulse) for that event, and the nurse only placed a note in the physician book rather than directly contacting the provider. Review of the physician binder showed an entry stating the resident was confused and had blood in her stool and “need to be checked,” but facility-provided provider notes contained no evidence that a provider ever evaluated the resident for the low oxygen saturation, confusion, and blood in the stool. Interviews with LPNs and the Unit Manager indicated that facility practice and standing orders required obtaining a full set of vitals, initiating oxygen per protocol, and directly contacting the provider for new issues or acute changes in condition such as altered mental status, low O2 saturation, and possible GI bleed. The DON confirmed that the nurse should have called the physician immediately rather than relying on the physician log, especially given the holiday week and upcoming weekend, and that the failure to call represented a deviation from the facility’s Acute Change in Condition policy, which requires urgent phone calls for significant changes such as abrupt confusion and frank blood in stool.
Failure to Report Resident-to-Resident Physical Incident to State Agency
Penalty
Summary
The facility failed to report a resident-to-resident physical incident to the State Agency as required. Two residents with significant cognitive impairments were involved: one with schizophrenia and anxiety, and another with Alzheimer's disease, depression, and dementia. The incident occurred when one resident approached another in the dining room, yelled, and struck her on the right upper arm. The event was witnessed by a Certified Occupational Therapist Assistant, who reported it to the nurse. The nurse completed an incident report and notified the Director of Nursing (DON) and Nursing Home Administrator (NHA). The interdisciplinary team discussed the incident and decided to send the resident who struck out to a psychiatric hospital. Despite internal documentation and discussion, the facility did not submit an initial report or a final investigation to the State Agency, as confirmed by a review of the Michigan Facility Reported Incident website. Interviews with staff revealed uncertainty about whether the incident was reported to the State Agency, and the facility's policy required such incidents to be reported. The lack of reporting resulted in an incomplete investigation and the potential for continued resident-to-resident incidents.
Failure to Apply Recommended Hand Splint for Resident
Penalty
Summary
The facility failed to ensure that a left resting hand splint was applied to a resident as per therapy recommendations, which could potentially lead to contracture progression, pain, and a decline in range of motion. The resident, a female with vascular dementia and stiffness of the hand, was observed multiple times without the splint, despite therapy recommendations for its use when out of bed. The care plan indicated the need for the splint, but there was no physician order for it, and staff were unaware of its current status. Interviews with staff, including a CNA, PT, LPN, and the DON, revealed a lack of awareness and documentation regarding the splint's application and the resident's refusal to wear it. The PT confirmed that the splint was recommended to manage contracture progression and pain, and training was provided to the nursing staff. However, the LPN and DON acknowledged the absence of a physician order and documentation of any refusal by the resident to wear the splint, indicating a breakdown in communication and documentation processes within the facility.
Inadequate Catheter Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide adequate monitoring, assessment, and care for a resident with an indwelling catheter, leading to hospitalization due to a severe urinary tract infection (UTI) and sepsis. The resident, who had a history of urinary retention and recurrent UTIs, was admitted with a chronic indwelling Foley catheter. Despite clear signs of infection, including cloudy and bloody urine, and abnormal urinalysis results indicating a UTI, the facility did not take timely action to address the resident's condition. The resident's urology visit notes indicated the need for immediate catheter change and urine culture and sensitivity (C&S) testing, which were not performed within the recommended timeframe. There was a significant delay in obtaining and acting upon the urine test results, with no documentation of nurse's notes or physician visits for several days. The resident's vital signs were not regularly monitored, and there were no orders for catheter care or monitoring documented in the Treatment Administration Record (TAR). Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and test results. The Director of Nursing (DON) was not informed of the urologist's orders, and there was no process in place to ensure timely receipt and action on visit notes and test results. The resident's condition deteriorated, leading to hospitalization with septic shock due to a urologic infection, highlighting the facility's failure to provide appropriate care and monitoring for the resident's catheter and urinary health.
Failure to Provide Adaptive Dining Equipment as Ordered
Penalty
Summary
The facility failed to provide adaptive dining equipment as per the physician's order for a resident with vascular dementia, lack of coordination, and hand stiffness. The resident had a physician's order for a regular diet with mechanical soft texture and thin liquids consistency, requiring a divided plate for all meals. However, during an observation, the resident was served a meal on a regular flat plate instead of the specified divided dish, which was noted on the resident's tray ticket. The registered dietitian confirmed that the resident sometimes needed assistance with eating and that the divided dish was essential for the resident's self-feeding ability. The divided plate helped the resident see the food better and facilitated getting food onto utensils due to the edges in each well of the plate. The failure to provide the divided plate as ordered resulted in the potential for difficulty with self-feeding and weight loss for the resident.
Failure to Maintain Accurate Medical Records and Monitor Resident's UTI
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, resulting in a lack of documentation related to catheter care, test results, vital signs, and resident status concerning an impending urinary tract infection (UTI). The resident was admitted with a diagnosis of urinary retention and exhibited symptoms such as being pale, not eating or drinking, and having cloudy and bloody urine. Despite these symptoms, there was a significant gap in documentation, with no nurse's notes or physician visits recorded between certain dates. The urinalysis results, which indicated a serious infection, were not promptly addressed, and there were no orders for catheter care or monitoring in the resident's Treatment Administration Record. Interviews with staff revealed that the resident's abnormal urinalysis results were not acted upon in a timely manner, and there was a lack of regular monitoring for signs of a UTI. The CNA tasks showed that catheter care and output were not documented for the past 30 days. The Director of Nursing and Infection Preventionist acknowledged the absence of documentation for the resident's symptoms and the need for regular monitoring, given the resident's history of repeated UTIs. The failure to document and follow up on the resident's condition led to the resident being sent to the emergency room.
Failure to Conduct Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to ensure that Quality Assessment and Assurance (QAA) meetings were held at least quarterly and that the required individuals attended these meetings. The review of the Quality Assurance and Performance Improvement (QAPI) meeting sign-in sheets showed that meetings were conducted on specific dates, but the Medical Director did not attend the meetings on two occasions. Additionally, there was a significant gap between meetings, with no QAPI meetings held from January 25, 2024, to August 29, 2024. During an interview, the Nursing Home Administrator acknowledged the absence of QAPI meetings during this period, stating that she had been meeting with each department head individually instead. The facility's QAPI policy requires the QAA Committee to meet at least quarterly and include specific members, such as the Director of Nursing Services, the Medical Director, and other staff members, to coordinate and evaluate activities under the QAPI program.
Infection Preventionist Training Deficiency
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) completed specialized training in infection prevention and control. During an interview, the Director of Nursing (DON) B, who was responsible for the infection control program, admitted to completing all modules of the CDC IP certification training but did not complete the post-test, resulting in her not having an IP certificate. Additionally, the Unit Manager (UM) LL, who assisted in the infection control program, reported not having completed the IP certification training and was not a certified IP. The Nursing Home Administrator (NHA) A was unaware that DON B had not completed the IP certification training.
Failure to Provide Annual Abuse Prevention Training
Penalty
Summary
The facility failed to provide the required annual abuse prevention education for all employees, which has the potential to affect all 79 residents residing in the facility. The deficiency was identified through interviews and record reviews, revealing that 33 out of 104 staff members did not receive the necessary training prior to the survey. The training is crucial for preventing abuse, neglect, and exploitation, especially for residents with dementia or Alzheimer's disease, who are at higher risk. The lack of training was attributed to staff being pulled to work on the floor, leaving insufficient time to complete the training. Interviews with staff members, including a CNA and the receptionist, highlighted the challenges in completing the training. The CNA mentioned that they could access the training application at home and submit a slip for payment upon completion. The receptionist was responsible for tracking training completion and sending reminders to employees. Despite these measures, the facility's records showed a significant number of staff had not completed the required training, indicating a systemic issue in ensuring compliance with the training schedule.
Inadequate Resident Activities in Dementia Care Unit
Penalty
Summary
The facility failed to provide consistent, meaningful, and person-centered activities for residents in the dementia care unit, affecting four out of seven residents reviewed. The activity calendar for the unit listed various activities, but during observations, these activities were not being conducted as scheduled. Residents were observed sitting idle or sleeping in common areas without engagement in any planned activities. The lack of individualized activities was evident, as residents were not seen participating in activities that matched their interests or care plans. Resident #16, with diagnoses including dementia and anxiety, was noted to have interests in music, crafts, and socializing. However, during the survey period, she was not observed participating in any of these activities. Similarly, Resident #56, who expressed interest in reading, music, and outdoor activities, was not seen engaging in these activities. The documentation for both residents showed a lack of recorded group activities and minimal one-on-one interactions. Resident #60, who valued music and social activities, was observed mostly asleep or idle in his wheelchair, with no engagement in activities that matched his preferences. Resident #178, who had interests in computers and trains, was not provided with activities related to these interests. The facility's activity staff faced challenges, such as understaffing and lack of training, which contributed to the deficiency in providing adequate activities for the residents.
Lack of Dietary Manager in Kitchen
Penalty
Summary
The facility failed to employ a dietary manager with the necessary training and certifications to oversee the kitchen, which increased the potential for food service sanitation failures and foodborne illness for all residents consuming food from the kitchen. During an initial tour of the kitchen, it was revealed that the facility had been without a dietary manager for over a month since the previous manager left. The dietary staff member interviewed was unsure about the schedule and responsibilities of the Registered Dietitian (RD), who reportedly visits the facility for about 8 hours a month but does not monitor the kitchen during these visits. The Nursing Home Administrator (NHA) acknowledged the absence of a dietary manager and mentioned attempting to assist in the kitchen despite being occupied with her own responsibilities. This lack of oversight and management in the dietary department was identified as a deficiency by the surveyors.
Improper Food Labeling and Dating in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling and dating of foods in the kitchen, which could potentially lead to the spread of foodborne illness to all residents consuming food from the kitchen. During an initial tour of the main kitchen, it was observed that the cook's reach-in refrigerator contained a bag of open cheese slices in a Ziploc bag with no label and date, and shredded pork thawing on a middle rack with ready-to-eat food below it. Additionally, the dietary aide's reach-in refrigerator had an open gallon of Vitamin D milk, an open gallon of 2% milk, and an 8-ounce milk in a cup covered with plastic wrap, all without labels or dates. On a subsequent tour, further issues were noted, including cranberry concentrate in a plastic container with a use-by date that had already passed, bread crumbs and thickener stored in large plastic containers with preparation dates but no use-by dates, and sugar stored without any label or date. The reach-in freezer also contained open bacon bits in a package with no label or date. These observations indicate a failure to comply with the 2017 FDA Food Code, which requires ready-to-eat, time/temperature control for safety food to be clearly marked with the date by which it should be consumed or discarded.
Deficiency in Behavioral Health Training Compliance
Penalty
Summary
The facility failed to ensure that 104 staff members received the necessary training for behavioral health care and services, as required by the facility assessment. This deficiency was identified through interviews and record reviews, revealing that 78 out of 104 staff members did not receive annual abuse prevention training before the survey began. Certified Nursing Assistant (CNA) V reported that the training was scheduled to be completed but faced challenges due to being pulled to work on the floor and having charting responsibilities, leaving little time for training. CNA V mentioned the option to complete training at home and submit a slip for payment. Receptionist EEE was responsible for running reports to ensure employees completed necessary classes before working on the floor. During orientation, Receptionist EEE checked that classes were completed and sent reminders to employees. The training was tracked electronically by Receptionist EEE, and reports were generated monthly by department to remind supervisors and employees. Administrator A confirmed that nursing staff would complete required training as needed, but the facility could not provide evidence of compliance for the majority of the staff.
Failure to Respect Resident's Right to Dignity and Self-Determination
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #20, who was cognitively intact and had diagnoses including osteomyelitis and end-stage renal disease requiring dialysis. The deficiency arose when the resident requested to be transferred to the hospital due to severe pain and the perception that the facility lacked adequate pain management. The Medical Director, referred to as MD WW, communicated with the resident via phone and denied the request for hospital transfer, stating it was not a life-threatening emergency and expressing concern about the number of hospital transfers. This interaction left the resident feeling angry and frustrated. The Licensed Practical Nurse (LPN) involved, identified as LPN EE, confirmed the resident's request and the subsequent conversation with MD WW, who emphasized the need to manage the number of hospital transfers. Despite MD WW's disapproval, the resident was eventually sent to the emergency room. During a follow-up interview, MD WW acknowledged the conversation and referred to the resident as a 'frequent flyer,' indicating a pattern of frequent hospital visits. This situation highlights the facility's failure to respect the resident's right to self-determination and dignified treatment, as the resident's concerns and requests were not adequately addressed.
Failure to Provide Proper Notification of Room Change
Penalty
Summary
The facility failed to provide proper notification of a room change to a resident, resulting in feelings of anger and frustration. The resident, who was cognitively intact and had diagnoses including osteomyelitis and end-stage renal disease with dialysis, reported being moved to a different room after a confrontation with a former roommate. Despite refusing the room change initially, the resident was moved without receiving any written notice or documentation of the change. The facility's policy requires written notice of room changes, including reasons for the move, but this was not adhered to in this case. Interviews with the Nursing Home Administrator and Social Services Director revealed inconsistencies in the documentation and communication regarding the room change. Both reported that the resident had refused the room change initially, but later agreed to it, although no documentation was available to support this claim. The Social Services Director was responsible for documenting and notifying residents of room changes, but failed to provide evidence of the resident's agreement or written notification of the room change. This lack of documentation and failure to follow policy led to the deficiency identified by the surveyors.
Failure to Maintain Accurate Advanced Directives
Penalty
Summary
The facility failed to maintain updated and accurate advanced directive information for two residents, leading to potential discrepancies in their medical care preferences. For Resident #12, there was a contradiction between the electronic medical record, which indicated a Full Code status, and a physical document in the code status binder that indicated a DNR (Do Not Resuscitate) status. The Director of Nursing (DON) and Unit Manager (UM) were unaware of the updated DNR directive completed in 2022, which had not been recorded in the electronic medical record. The Social Services Director (SSD) confirmed that the DNR directive was completed with the resident's POA in 2022 but was not entered into the medical record as per facility policy. For Resident #60, there was inconsistency in the resident's code status. The care plan and medical treatment decisions initially indicated a DNR status, but a subsequent update by the guardian changed the status to allow CPR. Despite this change, the family member confirmed the resident's preference for CPR in case of cardiac arrest. The Unit Manager stated that changes to the medical record should be made by the nurse who initiated the advanced directive, but this process was not followed, leading to discrepancies in the resident's code status documentation.
Resident Abuse During Shower by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff, specifically involving a resident with dementia and Alzheimer's disease. During a shower, a Certified Nursing Assistant (CNA) covered the resident's mouth and sprayed water in her face to prevent her from being heard yelling. This action was witnessed by another CNA who reported that the offending CNA often behaved inconsiderately and disrespectfully towards residents, causing discomfort during care. The incident led to increased agitation and mental anguish for the resident. Interviews revealed that the offending CNA had a history of similar behavior with other residents, but these concerns were not reported to management until the incident in question. Another CNA and a Licensed Practical Nurse (LPN) confirmed witnessing the abuse and reported it to the Nursing Home Administrator (NHA). The NHA acknowledged that this was the first reported concern against the offending CNA, although additional allegations surfaced post-termination. The facility had conducted a staff in-service prior to the incident, but it did not include education related to abuse.
Failure to Submit Investigation of Alleged Theft
Penalty
Summary
The facility failed to submit the investigation of an allegation of theft to the State Agency for one resident, resulting in the potential for the allegation to not be thoroughly investigated. The resident, who was cognitively intact, reported that money was stolen from their room and subsequently called the police and notified facility staff. The Nursing Home Administrator (NHA) initially reported the allegation to the State Agency on the day it was discovered. However, the NHA went on vacation the following day, and no one from the management team submitted the final investigation and report to the State Agency within the required five working days.
Failure to Complete PASARR and OBRA Level II Documentation
Penalty
Summary
The facility failed to ensure that the PASARR (Preadmission Screening/Annual Resident Review) documentation and OBRA Level II exemption criteria were completed appropriately for two residents. Resident #39, who has diagnoses including dementia, anxiety, psychotic disorder with delusions, major depressive disorder, insomnia, and traumatic brain injury, did not have an Annual Resident Review (ARR) from 2024 in his medical record. The social worker reported that her portion of the PASRR was uploaded, but she was unsure who was responsible for ensuring the provider completed their part. It was noted that it had been five months since Resident #39's PASARR should have been completed. Resident #60, with diagnoses including dementia, borderline personality disorder, anxiety, PTSD, and insomnia, did not have a letter from OBRA indicating exemption from continued Level II assessment or a completed OBRA Level II assessment. The social worker believed that due to the resident's dementia, he was exempt from a Level II OBRA assessment, despite the diagnosis of borderline personality disorder. The original PASRR completed prior to Resident #60's admission was not in the OBRA system, as the referring facility had handwritten it and never submitted it. The social worker submitted a new Level I PASRR into the OBRA system for review.
Deficiency in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) care for three residents, resulting in potential negative outcomes. Resident #16, a female with dementia and muscle weakness, was observed multiple times with unkempt facial hair, indicating a lack of personal hygiene assistance. Her care plan required limited to extensive assistance from one staff member for personal hygiene, which was not adequately provided. Resident #61, diagnosed with Alzheimer's disease and dementia, also exhibited signs of neglect in personal grooming. She was repeatedly observed with long facial hairs, despite her care plan specifying the need for grooming assistance according to her preferences. This lack of attention to her personal hygiene needs suggests a failure to adhere to her care plan. Resident #178, a male with a fractured humerus and dementia, was observed in a state of poor hygiene, wearing soiled clothing and an unshaven face. His care plan required extensive assistance from one staff member for personal hygiene, which was not met. Additionally, there was confusion regarding the necessity of his immobilizer, and staff reported difficulties in accessing razors for shaving. These observations highlight a significant lapse in providing necessary ADL care for these residents.
Failure to Prevent Pressure Ulcers in At-Risk Resident
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of pressure ulcers for Resident #54, who was at risk due to impaired physical mobility and a history of multiple pressure wounds. Despite physician orders for preventative interventions, including the application of a hydrocolloid dressing to the right hip, the resident missed 10 out of 13 treatment opportunities since the order was placed. Observations revealed that the resident was left sitting in a specialized wheelchair for extended periods without being repositioned, contrary to the care plan that required frequent repositioning to offload pressure. Interviews with facility staff, including CNAs, LPNs, and the Unit Manager, highlighted a lack of awareness and adherence to the prescribed treatment plan. The staff reported inconsistencies in the application of protective dressings and a misunderstanding of current treatment orders, with some staff unaware of the need for a protective dressing on the resident's right hip. Additionally, the resident's Braden Assessment, which should have been conducted quarterly, was last completed 11 months prior, indicating a lapse in regular risk assessment for pressure injuries.
Failure to Follow Transfer Protocols for Resident
Penalty
Summary
The facility failed to ensure that staff followed the care plan for transfer techniques for a resident, resulting in the potential for a fall or injury. The resident in question had diagnoses including dementia, abnormalities of gait and mobility, and lack of coordination, and was assessed as severely cognitively impaired. During an observation, a CNA was seen transferring the resident from the bed to a wheelchair without using a gait belt, despite having one in her possession. The CNA admitted to not using the gait belt and mentioned it was her first time caring for the resident, believing the resident required only a one-person transfer. The care plan for the resident specified that transfers required the assistance of two staff members and the use of a gait belt. Interviews with other staff members, including CNAs and nurses, confirmed that the resident was indeed a two-person transfer with a gait belt. The Director of Nursing also stated that the expectation was for a gait belt to be used for every transfer, except when using a mechanical lift. This oversight in following the care plan posed a risk of fall or injury to the resident.
Deficiency in Dementia Care and Staff Training
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident diagnosed with dementia, anxiety, and major depressive disorder. The care plan lacked comprehensive interventions to address the resident's cognitive and emotional needs, focusing primarily on medication administration and basic communication with family members. Despite the resident's expressed preferences for group activities and outdoor time, the care plan did not include specific strategies to engage the resident in meaningful activities or address her frequent tearfulness and agitation. Observations and interviews revealed that the resident frequently exhibited distressing behaviors, such as crying, delusions, and hallucinations, which were not effectively managed by the staff. The staff's attempts to redirect or console the resident were often unsuccessful, and there was a lack of consistent documentation and tracking of the resident's mood and behavior symptoms. The facility's behavior/mood symptom tracking tool was not consistently updated, and there was no evidence of a coordinated approach to managing the resident's symptoms. Additionally, the facility failed to provide adequate dementia care training for its staff, with 39 out of 104 employees lacking documented training. This lack of training likely contributed to the staff's inability to implement effective interventions for the resident's dementia-related behaviors. The facility's failure to ensure qualified staff and a comprehensive, person-centered care plan potentially compromised the resident's physical, mental, and psychosocial well-being.
Inaccurate Medical Records and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to discrepancies in medication administration and treatment documentation. For Resident #13, there was a failure to administer the correct insulin as per the physician's order. The resident was prescribed Novolog, but was instead given Humalog without updating the medical records to reflect this change. Interviews with the nursing staff and the pharmacist revealed that the pharmacy would send whichever insulin was available, and the nurses administered it without updating the physician's order in the computer system. Resident #69's medical records showed inaccuracies in the documentation of nebulizer treatments. Although the resident was scheduled to receive nebulizer treatments four times a day, observations and interviews indicated that the treatments were not consistently administered, and refusals were not properly documented. The Medication Administration Record (MAR) inaccurately reflected that treatments were given when they were not, as confirmed by the LPN who admitted to not administering the doses but still marking them as completed. For Resident #21, there was a failure to document wound care treatments accurately. The resident had a physician's order for daily wound care, but the Treatment Administration Record (TAR) showed multiple instances where the treatment was not documented as completed. Interviews with nursing staff revealed a lack of awareness regarding the missed treatments, and the DON noted that refusals should have been documented if they occurred, which was not done.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) during care for residents under enhanced barrier precautions (EBP), specifically for two residents with open wounds. For Resident #29, who was under EBP due to an open wound on the toe, multiple staff members, including CNAs and a hospice nurse, were observed not wearing gowns during high-contact care activities such as transfers and dressing assistance. Despite signage indicating EBP requirements, some staff members were unaware of the need for PPE or misunderstood which residents required it. Interviews with staff revealed inconsistencies in understanding and implementing EBP protocols, with some staff incorrectly believing that Resident #29 was not under EBP. Similarly, for Resident #41, who had an open malignant lesion on the back, staff were observed not wearing gowns during direct care activities, including incontinence care and wound dressing changes. The hospice nurse and CNA involved in Resident #41's care did not adhere to the EBP requirements, despite the presence of signage and the resident's documented need for enhanced precautions. Interviews with the Director of Nursing and other staff confirmed that the expectation was for gowns and gloves to be worn during any direct, hands-on care for residents under EBP, highlighting a failure in adherence to infection control protocols.
Failure to Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure timely offering of recommended Pneumococcal vaccines to eligible residents, specifically affecting two residents out of five reviewed for immunizations. Resident #5, who was over the age of 65 and admitted in February 2024, had historical vaccinations of Pneumococcal PPSV23 and PCV13 but was eligible for additional doses of PCV15 or PCV20. However, there was no documentation of education, consent, or declination in the resident's record. Similarly, Resident #14 had a historical dose of Pneumococcal PPSV23 but was also eligible for further vaccination. There was no record of this resident being educated, offered, or declining the vaccination. The Director of Nursing (DON) acknowledged the oversight during an interview, indicating that the facility had not ordered the necessary vaccines for these residents, nor had they documented any educational or consent processes. This lack of action resulted in the potential for developing vaccine-preventable diseases among the residents.
Failure to Document Staff COVID-19 Vaccination Status
Penalty
Summary
The facility failed to maintain proper documentation related to staff COVID-19 vaccinations. During an interview, the Director of Nursing (DON) reported that while the COVID-19 vaccine was available for staff, there was no documentation maintained regarding whether the vaccine was offered or declined by the staff. Additionally, the Nursing Home Administrator (NHA) was unaware of the requirement to keep records of staff education, vaccine offering, or tracking the vaccination status of facility staff.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that annual performance evaluations for Certified Nursing Assistants (CNAs) were completed, which could potentially impact the delivery of nursing and related services. The review of employee personnel files revealed that several CNAs, including CNA V, CNA W, and CNA T, had not received their annual performance evaluations. Interviews with CNAs and other staff members confirmed that these evaluations had not been conducted. CNA V, who had been employed at the facility for four years, reported not receiving any performance evaluations during her tenure. Similarly, CNA U, who worked specific days of the week, also reported not having received an evaluation. Further interviews with facility staff, including the Receptionist EEE and the Director of Nursing (DON) B, highlighted a lack of clarity and responsibility regarding the generation and completion of these evaluations. Receptionist EEE mentioned that the evaluations were previously on paper and was unsure of their current format. DON B indicated that the evaluations were supposed to be generated by human resources for the nursing department to complete, but this process had not been followed. Administrator A confirmed that the nursing department was responsible for these evaluations, which had not been conducted, indicating a breakdown in the facility's internal processes for staff performance management.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by multiple observations of dirt, debris, and dried liquid materials in various areas. On several occasions, surveyors noted dried material on the floors of resident rooms and hallways, as well as dirt and debris scattered throughout the facility. Specific instances included dried liquid running down walls, chunks of dirt resembling dried mud, and straw paper scattered across floors. Additionally, cobwebs were observed in a resident's room, indicating a lack of regular cleaning. Interviews with staff revealed inconsistencies in cleaning practices. A housekeeper reported mopping only half of the hallway at a time due to excessively wet mops, while the Maintenance Director, who also served as the housekeeping supervisor, described a cleaning routine that involved mopping one side of the hallway and then the other. The Maintenance Director also mentioned that deep cleaning was conducted once a month, but observations during the survey indicated that regular cleaning was insufficient, as evidenced by dirt and dried liquid on walls and floors, including areas near the laundry chute.
Failure to Maintain Safe Temperature Levels in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe and comfortable temperature in resident rooms, specifically affecting two residents, Resident #111 and Resident #114. Observations revealed that Resident #111's room was located at the end of a hallway where temperatures increased, and the room was notably hot and stuffy despite fans being present. The resident's care plan indicated a risk for nutritional problems due to malnutrition and weight loss, with interventions to offer hydration regularly. However, the room temperature was recorded at 80 degrees, and no air conditioning unit was present. Interviews with the Maintenance Director and Assistant Director of Nursing highlighted issues with the facility's cooling system. The Maintenance Director noted that the air conditioning units were inadequate for cooling individual rooms, especially those at the end of hallways. The Assistant Director of Nursing reported that temperature checks were being conducted hourly, but there was a lack of direction on how to perform these checks properly. Despite the high temperatures, residents were not moved to cooler areas, and there were no additional measures like offering ice cream or popsicles to help cool them down. Resident #114 also reported discomfort due to the heat, as his room lacked an air conditioning unit and fan, despite being designated to receive one. Temperature logs showed consistently high temperatures in several rooms, with some reaching up to 88 degrees. The facility's cooling system was further strained by a frozen rooftop unit, which was working overtime. Observations indicated that staff were not properly trained in taking room temperatures, as demonstrated by a CNA incorrectly using an infrared thermometer. Complaints from residents about the heat were noted, but the facility's response was insufficient to address the issue effectively.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper infection control protocols, specifically enhanced barrier precautions (EBP), for two residents, leading to a potential increase in the spread of infection. Resident #110, a female with multiple health issues including a stage 3 pressure ulcer, was observed in situations where staff did not don the required personal protective equipment (PPE) such as gowns and gloves. During an observation, a Hospice RN and a CNA entered the resident's room and provided care without wearing the necessary PPE, despite the presence of an EBP sign outside the room. The CNA acknowledged the oversight, and the RN admitted to being unaware of the updated EBP requirements. Similarly, Resident #114, a male with a diabetic ulcer and other health conditions, was also not provided care in accordance with EBP protocols. Observations revealed that CNAs entered the resident's room and performed care activities without donning gowns and gloves, as required by the EBP sign posted outside the room. The CNAs involved were either unaware of the EBP requirements or mistakenly believed the precautions applied to the resident's roommate instead. Interviews with staff, including CNAs and the Director of Nursing, confirmed a lack of compliance with EBP protocols. The facility's policy on EBP, which mandates the use of gowns and gloves during high-contact care activities for residents with wounds or infections, was not followed. This failure to implement EBP as per the facility's policy and CDC guidelines resulted in a deficiency citation for the facility.
Failure to Maintain Resident Dignity and Timely Care
Penalty
Summary
The facility failed to maintain an environment that promoted and enhanced resident dignity for two residents. Resident #111, who had diagnoses including muscle weakness, malnutrition, and anorexia, was observed with food debris on her bed and clothing after being assisted with a meal. Staff interviews revealed that it was standard practice to ensure residents were clean and free of food debris after meals, but this was not adhered to in Resident #111's case, potentially leading to feelings of humiliation and embarrassment. Resident #101, with diagnoses including heart failure, epilepsy, and kidney disease, experienced issues with staff responsiveness and treatment. A family member reported that the resident expressed dissatisfaction with the night CNAs, who allegedly made rude comments and delayed assistance, stating they were only required to change her every two hours. Despite complaints being documented, there was no indication that verbal abuse was reported to the Unit Manager or Director of Nursing, although concerns about staff behavior were noted.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, resulting in a lack of service to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The resident, a female with cerebral palsy, epilepsy, intellectual disabilities, and Rett's syndrome, had a care plan that included interventions such as wearing palm protectors and addressing skin integrity issues. However, observations revealed that these interventions were not consistently implemented. The resident was observed without necessary protective equipment, such as long fluffy socks and sheepskin braces, which were intended to prevent skin breakdown and contractures. The resident's feet were improperly positioned in the wheelchair, leading to abrasions and potential skin breakdown. Despite recommendations for a new wheelchair and adjustments to the current one, these measures were not promptly executed, leaving the resident vulnerable to further injury. Interviews with staff indicated a lack of consistent documentation and follow-through on care plan interventions. The Unit Manager and Registered Nurse acknowledged the absence of protective devices and the need for adjustments to the resident's wheelchair. The facility's failure to ensure the implementation of the care plan interventions contributed to the resident's compromised well-being.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for three residents, resulting in unmet personal hygiene needs. Resident #110, who has Alzheimer's, glaucoma, confusion, impaired balance, and limited mobility, was observed with plaque buildup and decaying teeth, indicating a lack of oral hygiene. The resident's care plan required assistance with personal hygiene, but showers were missed on several scheduled dates. Resident #111, with limited mobility, was observed with unbrushed teeth and disheveled hair, suggesting a lack of grooming. Despite the care plan indicating the need for assistance with personal hygiene, the resident's appearance showed neglect in these areas. Observations confirmed that the resident's teeth remained unbrushed and hair uncombed throughout the day. Resident #113, who is totally dependent on staff for personal hygiene due to cerebral palsy, epilepsy, intellectual disabilities, and Rett's syndrome, was observed with greasy, uncombed hair and plaque buildup on her teeth. The resident's care plan required extensive assistance with personal hygiene, but showers were missed on multiple occasions. Interviews with staff revealed inconsistencies in documenting refusals and providing necessary care, contributing to the deficiency.
Failure to Maintain Resident Hydration
Penalty
Summary
The facility failed to maintain sufficient hydration for Resident #111, a female with diagnoses including muscle weakness, muscle wasting, abnormal weight loss, and severe protein-calorie malnutrition. Her care plan, revised in December 2022, identified her as at risk for nutritional problems and included interventions such as offering hydration every shift and ensuring fluids were within reach. Despite these interventions, observations revealed that Resident #111's water was often left untouched and out of reach, indicating a lack of adherence to her care plan. Over a period of several days, documentation of Resident #111's fluid intake was inconsistent and often below her estimated needs of 1100-1400 ml per day. Observations showed that her water was frequently full and not consumed, and staff interviews indicated that she did not get out of bed and ate only 25-50% of her meals. The facility's policy required staff to offer fluids regularly, especially during hot weather, but this was not consistently done for Resident #111. Interviews with staff, including an LPN and the Director of Nursing, revealed expectations for regular rounding and offering drinks to residents, which were not met in Resident #111's case. The facility's hydration policy emphasized individualized interventions and regular monitoring, but these were not effectively implemented, leading to the potential for dehydration and unmet resident needs.
Failure to Update and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop, implement, and update person-centered care plans for three residents, resulting in potential unmet care needs and risk of injury. Resident #101 had multiple documented allergies, including anaphylaxis to penicillin, which were not included in the care plan. The Unit Manager/Licensed Practical Nurse (UM/LPN) confirmed that allergies should be verified on admission and a care plan should be created for any allergies, but this was not done for Resident #101. Resident #104 had a care plan that lacked specific information regarding his physical mobility and visual impairment. Despite being a double amputee and legally blind, the care plan did not specify the type of assistance required for ambulation or the use of assistive devices. The resident reported needing a mechanical lift for transfers and being legally blind, but these details were not reflected in the care plan. The UM/LPN acknowledged that care plans should be personalized and updated regularly, but this was not done for Resident #104. Resident #109's care plan was outdated and did not reflect his current transfer needs. The care plan indicated that the resident could transfer with two-person assistance and a gait belt, but observations and staff interviews revealed that he had been using a sit-to-stand mechanical lift for months. The Director of Therapy and other staff members confirmed the resident's current transfer status, but the care plan had not been updated to reflect this change. This discrepancy highlights a failure to keep the care plan current and accurate, potentially compromising the resident's safety and care quality.
Failure to Ensure Safe Resident Transfers
Penalty
Summary
The facility failed to ensure safe transfers of residents by not using gait belts during manual transfers and not having two staff members present during mechanical lift transfers. Specifically, a CNA transferred Resident #102 from a wheelchair to a bed without using a gait belt, despite the facility's policy requiring gait belts for all non-mechanical lift transfers. The CNA admitted to knowing the requirement but did not follow it. The resident had diagnoses including Alzheimer's disease, lack of coordination, and unsteadiness of feet, making the proper use of transfer aids crucial for safety. Additionally, Resident #109, who had diagnoses including cerebral infarction, Parkinson's disease, and seizures, was transferred by a CNA using a sit-to-stand lift without the assistance of a second staff member. The facility's policy mandates that two staff members must be present for mechanical lift transfers. The CNA confirmed that she performed the transfer alone, and the resident corroborated this account. The facility's policy and staff interviews consistently indicated that these procedures were not followed, leading to the potential for injury during transfers.
Failure to Ensure Proper Dialysis Communication and Physician Orders
Penalty
Summary
The facility failed to ensure proper pre and post dialysis treatment assessment and monitoring communication between the facility and the dialysis provider for two residents, resulting in a potential disruption in the continuity of care. Resident #101, who had diagnoses including dependence on renal dialysis, muscle weakness, and urinary tract infection, did not have a physician order for dialysis treatments. Similarly, Resident #104, diagnosed with end-stage renal disease, sepsis, and hypotension, also lacked a physician order for dialysis treatments. Interviews with staff revealed that dialysis communication sheets, which should include vital signs, medications given, and other assessment information, were not consistently sent with the residents to their dialysis appointments or returned to the facility with post-treatment information. This lack of communication and documentation was confirmed by multiple staff members, including a Unit Manager, Licensed Practical Nurses, and a Registered Nurse, who were unable to locate any dialysis communication forms for the residents in question. The deficiency was further highlighted by the fact that the dialysis center did not keep copies of the communication forms, relying entirely on the facility to maintain this critical documentation. The absence of these forms and the lack of physician orders for dialysis treatments for both residents were acknowledged by the staff during interviews. This failure in maintaining proper communication and documentation between the facility and the dialysis provider posed a risk of unrecognized adverse reactions or resident decline related to dialysis treatments, thereby disrupting the continuity of care for the affected residents.
Inaccurate Documentation of Resident Allergies
Penalty
Summary
The facility failed to maintain accurate medical records for Resident #101, resulting in inaccurate documentation of allergies. Resident #101 had pertinent diagnoses including dependence on renal dialysis, muscle weakness, and urinary tract infection. The Admission Record and Care Plan for Resident #101 indicated 'No Known Allergies,' which was inconsistent with the Discharge Service Communication that listed multiple allergies, including penicillin, morphine, fluoxetine, meperidine, and tramadol. The discrepancy was noted during a review of the resident's records and interviews with staff members, who provided conflicting interpretations of the hospital discharge paperwork indicating 'allergies not on file.' Licensed Practical Nurse (LPN) S, Registered Nurse (RN) W, and Unit Manager/Licensed Practical Nurse (UM/LPN) X had differing views on how to interpret and verify allergies from hospital discharge paperwork. The President of Clinical Operations (VPoCO) stated that if no allergies were documented on the discharge papers, the expectation was to document 'no known allergies.' However, a telephone interview with RN CC from the dialysis care center revealed that Resident #101 had documented allergies to morphine, penicillin, fluoxetine, meperidine, and tramadol since 2019. This inconsistency in allergy documentation highlights a failure in the facility's process for verifying and maintaining accurate medical records for residents.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for several residents, resulting in feelings of disappointment. During an observation, multiple residents were seen seated with their lunch trays in front of them but without staff assistance. Specifically, Resident #109 and Resident #111 were seated together with their lunch trays but no staff were present to assist them. Similarly, Resident #108 and Resident #110 were seated together, and Resident #110 received his lunch tray but was not assisted immediately. Resident #104 and Resident #112 were also observed without their lunch trays while other residents at their table had already received theirs. This delay in receiving and assisting with meals led to visible worry and disappointment among the residents, as noted by their comments and expressions. In an interview, the Director of Nursing (DON) acknowledged that it was a dignity concern for residents to have their food in front of them without assistance, as the food would get cold and it was not respectful to the residents. The facility's policy on promoting and maintaining resident dignity, which was revised recently, emphasizes the importance of treating each resident with respect and ensuring their quality of life. The observations and interviews indicate that the facility did not adhere to this policy during the dining experience of the residents involved.
Failure to Facilitate Resident-Initiated Discharge
Penalty
Summary
The facility failed to facilitate a resident-initiated discharge per the resident's choice, resulting in a delay in discharge and the accumulation of unnecessary service charges. Resident #102, who had multiple medical conditions including diabetes, diabetic neuropathy, a fractured right tibia, and heart disease, expressed a desire to move to an assisted living facility (ALF). Despite multiple requests from the resident and his family, the facility did not promptly send the necessary referral to the ALF, causing a significant delay in the resident's discharge process. The resident was discharged from physical therapy and was ready to transition to the ALF, but the facility's inaction postponed this move, leading to additional private pay charges for services that were no longer required. The Social Work Director (SSD) was on maternity leave during a critical period and was not aware of the resident's discharge plans. Upon her return, she completed the referral, but this was after several weeks of delay. The family member reported leaving multiple messages with the facility, including the Administrator, without receiving a response. The delay in sending the referral was only resolved after the family contacted the Ombudsman. The resident was eventually discharged to the ALF, but not before incurring additional costs due to the facility's failure to act in a timely manner.
Failure to Complete Accurate Resident Assessments
Penalty
Summary
The facility failed to complete accurate assessments for a resident, resulting in an inaccurate reflection of the resident's status. The resident, who had multiple pertinent diagnoses including diabetes, diabetic neuropathy, a fracture of the right tibia, a wound on the right great toe, and peripheral vascular disease, was admitted with specific skin conditions noted by the referring hospital. However, the facility's admission assessment did not accurately document these conditions. The skin assessment completed on 11/15/23 failed to include descriptions of blisters, redness to the shin area, or the wound on the right great toe, despite these issues being present and noted in the transfer documentation from the hospital. This omission resulted in an incomplete and inaccurate assessment of the resident's skin integrity and overall health status. The Director of Nursing (DON) confirmed that the skin assessment lacked necessary details and acknowledged that the nurses were educated on completing assessments during their initial orientation. However, the deficiencies in the assessment process were evident as the critical skin conditions were not documented properly. During an interview, the DON reviewed the skin assessment and confirmed that the blisters, redness, and the right great toe ulcer were not noted in the assessment. The DON also mentioned that new admissions and their needs were discussed during morning meetings, but the specific skin issues of this resident were not captured in the assessment. This failure to accurately document the resident's skin conditions upon admission highlights a significant lapse in the facility's assessment process, potentially leading to impaired medical and functional problems due to unidentified needs.
Failure to Establish Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to completely assess and establish a baseline care plan for a resident within 48 hours of admission. The resident, who was admitted with multiple significant diagnoses including diabetes, diabetic neuropathy, a right tibia fracture, a wound on the right great toe, heart disease, muscle weakness, urinary retention, a left leg amputation below the knee, peripheral vascular disease, and prostate cancer, did not have a baseline care plan in place to address his activities of daily living (ADL) needs. Despite being cognitively intact with a BIMS score of 15 out of 15, the resident's baseline care plan was not completed until several days after admission, resulting in a lack of person-centered, resident-specific ADL care instructions for the nursing staff. The review of the records indicated that the baseline care plan summary was completed late and lacked the resident's signature to verify that the summary was provided. The comprehensive care plan was not initiated until several days after the resident's admission. The Director of Nursing confirmed that the baseline care plan should have been completed within 48 hours of admission to ensure that nursing staff had the necessary care plan focuses and interventions to provide effective and person-centered care. The facility's policy on baseline care plans, revised in January 2024, mandates that such plans be developed within 48 hours of admission and include essential healthcare information, but this was not adhered to in this case.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with multiple complex medical conditions, including cerebral palsy, epilepsy, intellectual disabilities, and Rett's syndrome. The care plan, revised on 10/27/23, indicated the use of palm protectors at all times, but there was no order for hand paddles for contractures in the resident's upper extremities. Observations on 2/16/24 revealed that the resident had a paddle pad in her left hand but not in her right hand, which was contracted. Interviews with staff indicated that the care plan was not fully implemented, and the necessary orders were not documented in the resident's medical record. Certified Nursing Assistant (CNA) U and Licensed Practical Nurse (LPN) BB reported that they relied on paper records and assignment sheets, which were not always updated with the latest care plan changes. The Director of Nursing (DON) B confirmed that an order for the hand paddles was missing and that the resident had them upon admission from an Adult Foster Care (AFC) facility. The DON also mentioned that staff were expected to implement care plan interventions during walking rounds, but this was not consistently done, leading to a lack of service for the resident to maintain her highest practicable physical, mental, and psychosocial well-being.
Failure to Follow Professional Standards of Nursing Practice
Penalty
Summary
The facility failed to follow professional standards of nursing practice for a resident with multiple health conditions, including diabetes, a fractured tibia, and a wound on the right great toe. Upon admission, there were no orders in place for catheter care and monitoring, despite the resident having a Foley catheter due to chronic urinary retention. The medical record review revealed no orders for catheter care, Foley size, catheter secure device, change catheter bag, monitor input/output, or catheter bag positioning. Additionally, there were missing entries in the Treatment Administration Record (TAR) for catheter care, indicating a lack of proper documentation and follow-up on the resident's catheter care needs. Interviews with staff confirmed that the necessary orders were not obtained or followed up on, leading to a gap in care for the resident's urinary catheter needs. The facility also failed to ensure that the resident's wound was properly assessed and treated. The resident had a wound on the right great toe, but the Treatment Administration Record (TAR) for November, December, and January revealed missed dressing changes and no documentation of dressing change refusals. There were no skin/wound notes, measurements, or documentation of the wound's condition and progress in the medical record. Interviews with staff indicated that the wound nurse was not informed of the resident's wound, and there was a lack of communication and follow-up regarding the wound care. The Director of Nursing (DON) confirmed that there were missed dressing changes and no treatment or monitoring for the blisters or redness on the resident's shin. Furthermore, the facility failed to ensure that the resident received follow-up care with an orthopedic surgeon as recommended. The resident had a fractured tibia and was supposed to have a follow-up appointment with an orthopedic surgeon within 1 to 2 weeks of admission. However, the appointment was canceled due to a lack of transportation, and the resident was not rescheduled to see the orthopedic surgeon until a month later. The medical record review revealed that an x-ray order for the resident's right tibia was not completed, and there was no explanation for the delay. Interviews with staff confirmed that there was a lack of coordination and follow-up for the resident's orthopedic care, leading to a delay in necessary medical evaluation and treatment for the fractured tibia.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to ensure assistance with Activities for Daily Living (ADL) care for two residents, resulting in potential negative physical and psychosocial outcomes. Resident #102, a male with multiple diagnoses including diabetes, diabetic neuropathy, and a below-knee amputation, was not provided with the necessary assistance for bathing and toileting. Despite being scheduled for showers or bed baths on multiple dates, documentation showed that these were either not provided or not properly recorded. Additionally, the resident was left in briefs despite being continent, which caused him embarrassment and discomfort. The resident's request for a trapeze to assist with transfers was also not fulfilled, further impacting his ability to perform ADLs independently. Resident #108, a female with cerebral palsy, epilepsy, and Rett's syndrome, was also neglected in terms of personal hygiene and grooming. Observations revealed that her hair was consistently matted and uncombed, and she had facial hair that was not attended to. Her bathing schedule was not adhered to, with multiple dates showing no completed shower sheets. The resident's hand paddles for contractures were found to be soiled, and she was observed with a dry mouth and white liquid running down her chin. Interviews with staff indicated that proper procedures for reapproaching residents who refused showers were not consistently followed, and documentation was often incomplete or missing. The deficiencies in ADL care for both residents highlight a failure in the facility's processes for ensuring that dependent residents receive the necessary assistance. The lack of proper documentation and follow-up on refusals, as well as the failure to maintain residents' dignity and hygiene, contributed to the overall neglect observed in these cases. Interviews with staff and family members corroborated the findings, indicating systemic issues in the facility's care practices.
Failure to Ensure Proper Assessment and Treatment for Pain and Diabetes
Penalty
Summary
The facility failed to ensure quality care for two residents, Resident #101 and Resident #102, as evidenced by inadequate assessment and treatment for reported pain and elevated blood glucose levels. Resident #101, who was admitted with muscle weakness and type 2 diabetes, began reporting left foot pain on 12/24/23. Despite the pain and swelling, the staff did not adequately assess or treat the condition. An x-ray was ordered on 12/28/23, which showed no fractures, but no further assessment was conducted. The resident's condition worsened, with therapy staff noting swelling, bruising, and a possible pressure ulcer on 1/6/24. The facility's records did not show any orders or follow-up actions taken by the physician, MD Q, despite multiple reports of pain and elevated blood glucose levels from the nursing staff and family members. Resident #102, who had multiple diagnoses including diabetes and diabetic neuropathy, also did not receive proper diabetic monitoring. The resident's care plan included monitoring blood glucose levels and administering diabetes medication, but the facility failed to document any monitoring of blood sugar, labs, or the effectiveness of the medication from November 2023 to January 2024. The Director of Nursing (DON) B confirmed that there should have been at least monthly labs and daily Accu-Checks, but these were not performed. Interviews with staff revealed a lack of communication and follow-up regarding the residents' conditions. RN S did not recall notifying the wound nurse or the doctor about Resident #101's foot condition, and LPN-UM O was unaware of any assessments for high blood glucose levels. The facility did not have a system in place to ensure that reported concerns were addressed by the physician, leading to a delay in treatment and potential worsening of the residents' medical conditions.
Failure to Provide Proper Wound Care
Penalty
Summary
The facility failed to accurately assess, monitor, treat, and implement interventions for residents with pressure ulcers. Resident #100, who was cognitively intact, reported that the facility staff were not completing dressing changes for his pressure ulcer as ordered. Observations and interviews revealed that the dressing changes were not being performed daily as required, and there was inconsistent documentation of the wound care provided. The Treatment Administration Record (TAR) showed discrepancies in the documentation, with some dressing changes marked as completed when they were not, and missing documentation for certain days. The Licensed Practical Nurse (LPN) and Unit Manager were unable to explain these inconsistencies, and there was no system in place to monitor and ensure that the ordered treatments were being administered properly. Resident #102, who had multiple pertinent diagnoses including diabetes and a right great toe wound, also did not receive proper wound care. The resident's care plan included specific instructions for monitoring and treating the wound, but there were no orders for the treatment or monitoring of additional blisters and shin redness. The Treatment Administration Record (TAR) for several months showed multiple instances where dressing changes were not completed, and there was no documentation of refusals. Additionally, there were no skin/wound notes, measurements, or documentation of the wound's condition and progress. Interviews with the LPN and Director of Nursing (DON) revealed a lack of communication and coordination in notifying the wound nurse about new wounds and ensuring proper follow-up and documentation. The facility's policy on wound treatment management emphasized evidence-based treatments and thorough documentation, but these standards were not met in the cases of Resident #100 and Resident #102. The lack of accurate assessment, monitoring, and documentation of wound care led to deficiencies in the care provided to these residents, with potential risks for worsening conditions. The facility did not have adequate processes in place to ensure that wound care treatments were administered as ordered and properly documented.
Failure to Address Resident's Pain and High Blood Glucose Levels
Penalty
Summary
The facility failed to complete a medical evaluation of a resident's condition, review the appropriateness of the resident's medical treatment, and implement orders, resulting in unresolved pain and untreated high blood glucose levels for a resident. The resident, who was admitted with muscle weakness and type 2 diabetes, began reporting left foot pain, which was not adequately addressed by the staff. Despite an x-ray showing no fractures, the resident continued to experience pain, swelling, and eventually developed a pressure ulcer on her ankle, which was not properly assessed or treated by the physician or nursing staff. The resident's blood glucose levels were also not adequately monitored or managed. Elevated blood glucose levels were recorded multiple times, but there was no evidence that the physician assessed or addressed these concerns. The facility's log book indicated that the physician was notified of the high blood glucose levels and the foot edema, but there were no documented actions taken by the physician to address these issues. Interviews with staff revealed that there was a lack of follow-up and communication regarding the resident's condition. The physician did not recall assessing the resident's foot or ankle, and the nursing staff did not ensure that the physician was informed of the ongoing issues. Additionally, there was no system in place to monitor the physician log book or skilled nursing notes to ensure that reported concerns were being addressed, leading to the resident's unresolved pain and untreated high blood glucose levels.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure timely physician visits for a resident, resulting in the potential for unmet medical needs. Resident #102, a male with multiple pertinent diagnoses including diabetes, diabetic neuropathy, a fracture of the right tibia, a wound on the right great toe, falls, heart disease, muscle weakness, urinary retention, an acquired absence of the left leg below the knee, peripheral vascular disease, and prostate cancer, did not receive a required physician visit in December 2023. The resident was cognitively intact with a BIMS score of 15 out of 15. The medical record showed that the resident was seen by the physician on 11/13/23, 11/20/23, 11/27/23, 1/4/24, and 1/8/24, but there was no visit recorded for December 2023, which is a requirement for the first 90 days after admission. Interviews with facility staff, including the Medical Records AA, LPN, and DON, confirmed that the physician did not visit the resident in December 2023. The Medical Records AA reported that the provider came to the facility twice a week, and the LPN confirmed the physician's visits on Mondays and Thursdays. The DON reviewed the medical record and confirmed the absence of a December visit. The physician, MD Q, indicated that if his progress notes did not discuss an assessment or new orders, he would assume he had not assessed the resident for those conditions. The facility's policy requires the physician to see the resident within 30 days of initial admission and at least once every 30 days for the first 90 days, which was not adhered to in this case.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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