The Orchards At Samaritan
Inspection history, citations, penalties and survey trends for this long-term care facility in Detroit, Michigan.
- Location
- 5555 Conner Avenue, Suite 4000, Detroit, Michigan 48213
- CMS Provider Number
- 235632
- Inspections on file
- 30
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at The Orchards At Samaritan during CMS and state inspections, most recent first.
A resident with chronic systolic CHF, acute kidney failure, and a traumatic subarachnoid hemorrhage, and with intact cognition, had a physician order for a one-time Albuterol nebulizer treatment for SOB. The MAR showed the treatment was given as ordered, but a subsequent nursing note documented that an additional breathing treatment was administered when the resident was found short of breath, with the nurse explaining it as part of new prednisone therapy. There was no physician order for this repeat nebulizer treatment, and facility policy required medications to be given only on clear, complete, signed prescriber orders.
A resident with severe cognitive impairment and a history of right shoulder dislocation was physically abused by a CNA, who forcefully twisted the resident's arm during care, resulting in a dislocated shoulder and hospitalization. The incident was witnessed by another CNA, who delayed reporting due to fear of retaliation. The resident required two-person assistance, but this protocol was not followed at the time of the incident.
A resident with severe cognitive impairment and a recent shoulder injury was subjected to physical abuse by a CNA, who forcefully twisted the resident's arm during care. The incident was not immediately reported to the charge nurse due to fear of retaliation, and there was a delay in notifying the NHA and state authorities as required by facility policy. The resident sustained a dislocated shoulder and required hospital treatment, while the facility failed to report the involved CNA's license to the state agency.
A CNA engaged in a loud verbal altercation with two residents, one with cancer and intact cognition and another with severe dementia, using profane, derogatory, and racially charged language. The incident was witnessed and documented by staff, and the facility's policy prohibits such abuse. Leadership acknowledged the behavior was not in line with facility standards.
The facility did not maintain RN coverage for eight consecutive hours daily, as required, with a specific lapse on a day in October 2024. The staffing coordinator admitted challenges in weekend RN coverage, and the DON sometimes filled in, though this did not meet requirements when the census was over 60 residents. The facility lacked a specific RN coverage policy, relying instead on CMS guidelines.
The facility failed to employ sufficient dietary staff, leading to inadequate sanitation in the kitchen, potentially affecting 99 of 104 residents. Observations revealed understaffing, with the Food Service Supervisor performing multiple tasks due to a staff shortage. A cleaning schedule was not provided, and the dietary department was consistently understaffed, particularly on Mondays and Fridays. The Administrator acknowledged staffing was under review, but no explanation was given for the lack of monitoring and oversight.
The facility's kitchen was found to be unsanitary, with improper use of beard restraints by a cook, unsafe food temperatures, and unclean equipment. Potato salad was stored at 60°F without proper cooling, and the kitchen's exhaust hoods were heavily soiled. The Food Service Supervisor could not provide recent cleaning documentation, indicating a lack of oversight.
A facility failed to ensure proper cleaning and disposal of loose medications in a medication cart. An observation revealed 19 loose pills of various shapes, colors, and sizes scattered in the drawers of the 400 Hall medication cart, along with dried stains, lint, and dust. Nurse G acknowledged the cart should have been clean and stated that loose pills should be discarded. The DON confirmed that nurse managers were responsible for maintaining the cleanliness of medication carts. The facility's policy required medication storage areas to be clean and clutter-free.
A resident's room in the facility had a hole in the floor that was not repaired for a year, leading to frustration and a potential hazard. The Maintenance Supervisor acknowledged the issue but had not created a work order, and the facility lacked a formal work order system. The Nursing Home Administrator recognized the tripping hazard, especially given the resident's moderately impaired cognition and weak ambulation. The facility's policy on regular room maintenance was not adhered to, resulting in this deficiency.
A resident receiving oxygen therapy was found with an unsecured oxygen tank at their bedside, posing a potential safety hazard. The tank was fully pressurized and not stored in a medical rack or stand, contrary to the facility's policy. The resident had a complex medical history but intact cognitive function. The DON acknowledged the risk associated with the free-standing tank.
The facility failed to properly manage oxygen therapy for two residents. One resident's oxygen tubing was not labeled, and the concentrator was unclean, despite care plan instructions. Another resident wore oxygen without a physician's order, and the tubing was also unlabeled. Both residents had intact cognitive function and significant medical histories.
A facility failed to address MRR recommendations timely, resulting in unnecessary medications for a resident with intact cognition and multiple diagnoses. Duplicate orders for Famotidine were administered, and Lidoderm patch usage exceeded recommended duration. The DON acknowledged the physician's lack of response to the pharmacist's irregularity reports.
The facility failed to prevent unnecessary medications for two residents, leading to potential adverse effects. One resident received prolonged Guaifenesin without a stop date, while another had duplicate Famotidine orders. The DON acknowledged the issues, and the facility lacked an unnecessary medication policy.
Surveyors found that the facility did not maintain a clean and safe environment, with heavily soiled kitchen vents, broken and dirty equipment, missing or stained ceiling tiles, and unclean resident rooms. Observations included food residue, debris, and unsanitary conditions in both common areas and resident rooms, with staff interviews confirming lapses in cleaning procedures and maintenance responsibilities.
A resident with oral cancer experienced uncontrolled pain due to the facility's failure to administer Oxycodone as prescribed. The resident's pain medication was delayed or withheld without proper justification, leading to significant distress and eventual discharge against medical advice. Interviews and records revealed lapses in following medication administration policies.
A facility failed to report an allegation of employee-to-resident abuse to the State Agency, involving a cognitively intact resident who was allegedly slapped by a staff member. Despite complaints being reported to the state hotline, the facility did not submit a Facility Reported Incident (FRI). The Nursing Home Administrator concluded the incident did not occur and did not report it, contrary to the facility's policy requiring timely reporting of such allegations.
A resident with a history of multiple health conditions experienced critical anemia symptoms and lab results, but the facility failed to timely address these issues. Despite discontinued iron supplements and decreased iron levels, no changes were made to the care plan, leading to hospitalization for anemia, fluid overload, and acute kidney injury. The DON and physician could not explain the delay in intervention, and the facility's policy on acute change in condition was not followed.
A resident with multiple diagnoses, including chronic pain, was prescribed Oxycodone HCl. An LPN signed out two tablets from the Pyxis system, although only one was administered, citing preparation for the next shift. The DON confirmed this was against standard practice, as narcotics should be signed out only at the time of administration.
A resident with severe cognitive impairment exited the facility without staff knowledge, despite being last seen at a bingo event. The resident was found the next morning by police, having left through the main elevator. Staff interviews confirmed the resident was reported missing later in the evening, highlighting a lapse in supervision.
The facility failed to provide timely incontinence care for a resident, resulting in a strong urine smell and heavily saturated briefs on multiple occasions. Despite the care plan requiring checks and changes every two hours, staff interviews and observations confirmed that this protocol was not followed.
Unauthorized Repeat Administration of Nebulizer Treatment Without Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to administer medications according to physician orders for one resident. The resident had diagnoses including chronic systolic congestive heart failure, acute kidney failure, and traumatic subarachnoid hemorrhage, and had an intact cognition score of 15/15 on the Brief Interview for Mental Status. A physician’s order dated 2/17/26 directed that Albuterol Sulfate Inhalation Nebulization (2.5 mg/3 mL 0.083%) be given as one vial via nebulizer one time only for shortness of breath for one day. The February 2026 medication administration record showed that this nebulizer treatment was administered on 2/17/25 in accordance with the order. However, a nursing progress note dated 2/18/2026 at 20:03 documented that the resident was found sitting in a chair with pants off and experiencing some shortness of breath, and that the writer (nurse) administered a breathing treatment and explained to the resident that the doctor had started them on a new medication, prednisone, to help reduce shortness of breath and help their lungs. The note further documented that the resident tolerated the medications well, could make needs known, was continent of bowel and bladder, and had vital signs recorded. There was no physician order for an additional breathing treatment beyond the original one-time-only nebulizer order, and the DON confirmed that the order was for one time only and should not have been given again without a physician’s order. The facility’s Medication Orders Policy stated that medications are to be administered only upon the clear, complete, and signed order of an authorized prescriber.
Failure to Protect Resident from Physical Abuse Resulting in Injury
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including dementia and polyneuropathy, required total assistance with activities of daily living. On the night in question, a Certified Nursing Assistant (CNA) was observed by another CNA forcefully twisting the resident's right arm behind their back during care, after expressing frustration and making an inappropriate comment. The resident was noted to be squirming and attempting to free their arm, and the incident was not immediately reported to the charge nurse due to fear of retaliation. Following the incident, the resident was assessed by a registered nurse, who initially found no injuries and noted the resident could move both arms without apparent pain. However, a subsequent assessment revealed slight bruising and pain when the right arm was raised. Diagnostic imaging later confirmed a dislocated right shoulder, and the resident was transferred to the hospital for treatment. The incident was reported to law enforcement, and the CNA involved was suspended and later terminated. The facility's documentation and interviews revealed that the resident required two-person assistance for care, but the incident occurred with only one CNA present initially. The other CNA, who witnessed the abuse, did not immediately report the event due to concerns about retaliation, resulting in a delay in addressing the situation. The resident's medical record indicated a history of right shoulder dislocation, and the incident led to further injury and hospitalization.
Failure to Timely Report Suspected Physical Abuse and Injury
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of a reasonable suspicion of physical abuse involving a resident with severe cognitive impairment and multiple medical conditions, including dementia and a recent right shoulder dislocation. On the night in question, a CNA observed another CNA forcefully twisting the resident's right arm behind their back during care, causing the resident to squirm and attempt to free themselves. The observing CNA did not immediately report the incident to the unit charge nurse due to fear of retaliation and instead reported it to the Nursing Home Administrator (NHA) approximately two hours later. The resident was later found to have a dislocated shoulder and was transferred to the hospital for treatment. The facility's policy required immediate reporting of abuse allegations to the Administrator and the State Agency, especially when serious bodily injury is involved. However, the incident was not reported to the appropriate authorities within the required timeframe, and the NHA did not report the involved CNA's license to the state agency as required. The delay in reporting and failure to follow established procedures resulted in the abuse going unreported in a timely manner, placing the resident at further risk.
Failure to Prevent Verbal Abuse by CNA Toward Two Residents
Penalty
Summary
The facility failed to prevent verbal abuse involving two residents, one with intact cognition and a diagnosis of ovarian cancer, and another with severe cognitive impairment and dementia. On the date of the incident, a Certified Nursing Assistant (CNA) was witnessed by another CNA and documented by a Registered Nurse (RN) to have engaged in a loud verbal altercation with the residents, using profane and derogatory language. The CNA directed explicit insults and threats toward both residents, including referencing one resident's terminal illness in a disparaging manner and using racial and gender-based slurs. The incident was reported by the affected resident to an LPN, and corroborated by staff witness statements and written documentation. The resident with intact cognition provided a detailed written account of the incident, while the resident with dementia was unable to recall the event during interview. Staff interviews and written statements confirmed the occurrence of the verbal abuse, with the RN noting the CNA's continued aggression until being removed from the unit. The facility's policy prohibits all forms of abuse, including verbal abuse defined as the use of disparaging or derogatory language toward residents. The actions of the CNA were acknowledged by facility leadership as inappropriate and not in accordance with established standards or policy.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week, as required. This deficiency was identified during a review of the nurses' schedule for October, November, and December 2024, which revealed a lack of RN coverage on October 20th, 2024. The staffing coordinator acknowledged difficulties in securing RN coverage for weekends and noted that the Director of Nursing (DON) sometimes covered shifts. However, the staffing coordinator was unaware that the DON's coverage does not count towards RN coverage when the facility census exceeds 60 residents. The DON confirmed that there were instances when an RN was unavailable and acknowledged the necessity of RN supervision for the resident population. Additionally, the facility lacked a specific RN coverage policy and instead referred to the Center for Medicare and Medicaid Services guidelines.
Inadequate Dietary Staffing and Sanitation in Kitchen
Penalty
Summary
The facility failed to employ sufficient dietary staff and ensure operational consultation was provided to supervisory staff, resulting in inadequate sanitation in the kitchen. This deficiency had the potential to affect 99 of the 104 residents who consumed meals from the kitchen. On the morning of 3/24/25, the Food Service Supervisor (FSS) D was observed performing multiple tasks, including collecting trays, transporting food carts, and organizing the walk-in refrigerator and freezer, due to a staff shortage. FSS D reported that one employee had called in sick that morning, and a dietary aide position had been vacant since the previous month. During an observation, FSS D was unable to provide a cleaning schedule, indicating a lack of structured sanitation monitoring. Further investigation revealed that the dietary department was consistently understaffed, particularly on Mondays and Fridays, with only three dietary aides and one cook available for breakfast and lunch. The Area Manager (A.M.) F confirmed the staffing shortage and acknowledged that the facility had scheduled 55 hours instead of the initially reported 51 hours. However, no explanation was provided for why the additional hours did not address the sanitation issues. The Administrator mentioned that staffing was under review but did not explain the lack of monitoring and oversight in the kitchen. Upon exiting the facility, the audit form for the department was found to be blank, and no cleaning schedule was provided as requested.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary kitchen environment for food storage, preparation, and service, which could potentially lead to foodborne illnesses affecting 99 of the 104 residents. Observations revealed that a cook was improperly using a beard restraint, covering his beard but not his mustache, which was later corrected. Additionally, during a lunch meal observation, potato salad was found at an unsafe temperature of 60 degrees Fahrenheit, without any cooling device to maintain the required temperature of 41 degrees Fahrenheit or below, as per the 2023 Food Code. Further inspection of the facility's main kitchen revealed cracked and detached caulking along the dish machine's scrape table, with standing water, food debris, and a black mold-like substance present. The kitchen's exhaust hoods were heavily soiled with grease, lint, and food ash, and the last professional cleaning was recorded on January 7, 2025, with the next scheduled for July 15, 2025. The Food Service Supervisor was unable to provide documentation of recent cleaning schedules or tasks, indicating a lack of oversight and adherence to sanitation protocols. These deficiencies were acknowledged by the Area Manager during a walkthrough but remained unaddressed by the time of the survey exit.
Improper Cleaning and Disposal of Medications in Medication Cart
Penalty
Summary
The facility failed to ensure proper cleaning and disposal of loose medications for one of the four medication carts observed. During an observation and interview with Nurse G, it was found that the 400 Hall medication cart contained 19 loose pills scattered across the bottom of the first and second drawers. These pills varied in shapes, colors, and sizes. Additionally, the drawers had dried tan stains, lint, and dust. Nurse G acknowledged that the cart should have been clean and stated that their policy required loose pills to be discarded. The Director of Nursing confirmed that nurse managers were responsible for checking and cleaning the medication carts on their units. A review of the facility's policy on medication storage indicated that medication storage areas should be kept clean and free of clutter.
Failure to Repair Resident's Room Floor Creates Hazard
Penalty
Summary
The facility failed to maintain a safe and homelike environment for a resident, identified as R95, by not repairing a hole in the floor of their room. The resident expressed frustration over the issue, which had persisted for a year without being addressed. The hole, approximately six by four inches in size, was located near the foot of the resident's bed and was observed during an interview with the resident. The Maintenance Supervisor acknowledged the issue but admitted that no work order had been created, and the facility lacked a formal work order system. This oversight resulted in the repair not being completed in a timely manner. The Nursing Home Administrator also acknowledged the hole in the floor, agreeing that it posed a tripping hazard and could not be cleaned properly. The resident, who was admitted to the facility with diagnoses including chronic heart failure and age-related physical debility, had a moderately impaired cognition as indicated by a BIMS score of 12/15. Additionally, the resident was assessed as a weak ambulator, which further emphasized the potential risk posed by the unrepaired floor. The facility's policy on resident room maintenance, which requires regular inspections and maintenance, was not followed, contributing to the deficiency.
Improper Storage of Oxygen Tank Poses Safety Hazard
Penalty
Summary
The facility failed to properly store an oxygen tank for one resident receiving oxygen therapy, which resulted in a potential safety hazard. During an observation, the resident was found in bed using oxygen via a nasal cannula, with the oxygen set at 2 liters through a concentrator. Next to the resident's bed was a green cylinder oxygen tank, which was fully pressurized but not secured in a medical rack or stand. This improper storage posed a risk of the tank tipping over, potentially causing damage or leaks. The oxygen tubing also lacked a date label, which is necessary for tracking and safety purposes. The resident involved had a complex medical history, including conditions such as stroke, seizures, atrial fibrillation, asthma, chronic obstructive pulmonary disease, diabetes type II, heart disease, and chronic pain. Despite these conditions, the resident had an intact cognitive function, as indicated by a Brief Interview for Mental Status score of 15/15. The Director of Nursing acknowledged the issue, noting that a free-standing oxygen tank could be dangerous. The facility's policy on oxygen use safety, revised in December 2009, clearly states that oxygen cylinders must be stored in racks, sturdy portable carts, or approved stands and should not be left free-standing or stored in resident rooms or living areas.
Deficiencies in Oxygen Therapy Management for Residents
Penalty
Summary
The facility failed to properly manage and document the use of oxygen therapy for two residents, R9 and R33. For R9, the oxygen tubing was not labeled with a date, and the resident was unsure of how frequently the tubing was changed. Additionally, the oxygen concentrator was observed to be unclean, with a thick white substance and dust debris present. R9's care plan and physician orders indicated that the oxygen tubing should be changed weekly and dated, but this was not adhered to. R9 has a history of morbid obesity, seizure disorder, COPD, diabetes mellitus type 2, anxiety, and heart failure, with an intact cognitive function as indicated by a BIMS score of 15/15. For R33, the oxygen tubing was also not labeled with a date, and there was no physician's order for supplemental oxygen therapy in the resident's electronic medical record. Despite wearing oxygen via nasal cannula, R33's care plan did not include an order for oxygen therapy. R33 has a medical history of stroke, seizures, atrial fibrillation, asthma, COPD, diabetes type II, heart disease, smoking, and chronic pain, with a BIMS score of 15/15 indicating intact cognitive function. The Director of Nursing acknowledged the deficiencies and stated that the issues would be addressed.
Failure to Address Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to address Medication Regimen Review (MRR) recommendations in a timely manner for a resident, resulting in the continuation of unnecessary medications and a lack of communication between the pharmacist and physician. The resident, who had intact cognition, was admitted with diagnoses including cerebral infarction, major depressive disorder, and anxiety disorder. The review of the resident's Electronic Health Record (EHR) revealed duplicate orders for Famotidine (Pepcid) 20mg, with one order written on 12/12/24 and another on 1/8/25. Both medications were administered until 2/24/25, despite being the same medication, indicating a failure to address the pharmacist's irregularity report. Additionally, the facility did not adhere to the pharmacist's recommendation regarding the use of Lidoderm patches, which should only be worn for 12 hours to avoid local adverse events. The Director of Nursing (DON) acknowledged that the physician did not respond to the irregularity reports and confirmed the oversight in the medication orders. The lack of timely response and communication regarding the pharmacist's recommendations contributed to the deficiency in the resident's medication management.
Failure to Prevent Unnecessary Medications for Residents
Penalty
Summary
The facility failed to ensure that two residents, R4 and R5, did not receive unnecessary medications, which could potentially increase the risk of adverse drug effects. Resident R5, who had severe cognitive impairment and required extensive assistance with activities of daily living, was administered Guaifenesin Oral Syrup for an extended period without a documented stop date or documented need for continued use. The Director of Nursing (DON) could not provide an explanation for the prolonged use of the cough syrup, which was initially prescribed for a cough related to COPD and congestion. The nurse practitioner did not respond to inquiries regarding the necessity of the medication. Resident R4, who had intact cognition and was diagnosed with cerebral infarction, major depressive disorder, and anxiety disorder, was found to have duplicate orders for Famotidine (Pepcid) 20mg. The duplicate medication was not discontinued until over a month after the irregularity was identified in a pharmacist's report. The DON acknowledged that the physician did not provide a timely response to the irregularity report, and the Nursing Home Administrator confirmed that the facility lacked an unnecessary medication policy.
Failure to Maintain Sanitary and Safe Environment in Kitchen and Resident Rooms
Penalty
Summary
The facility failed to maintain a safe and sanitary physical environment, particularly in the kitchen and several resident rooms. Observations revealed that multiple ceiling vents and covers in the kitchen, storeroom, emergency supply storage, and paper supply room were heavily soiled with soot, ash, and grease. Walls and storage areas for food carts were marked with black rubber scarring and had broken, chipped areas with exposed cement blocks. The dish room had soiled ceiling tiles and corroded metal strips, while several ceiling tiles in storage areas were stained or missing. Kitchen equipment, including a convection oven, stove, and deep fryer, was found to be cracked, missing parts, and covered in burnt food residue and grease. Floor tiles were broken or missing, allowing debris to collect, and floor drains and dish machine areas were dirty with food residue. The cleaning schedule and sanitation audits were not provided, and maintenance staff were unaware of their responsibilities regarding vent cleaning and tile replacement. In addition to the kitchen deficiencies, the facility failed to maintain cleanliness in specific resident rooms. One room had a ripped floor mat, dried substances on the floor, a tube feeding pole with dried yellowish residue, and a wall with broken plaster covered by tape. Housekeeping staff reported that mats should be sanitized daily and removed if damaged, and that tube feeding poles should be cleaned, especially if soiled. Another room was observed to have a dirty floor with debris, soiled tissues, food, garbage, piles of clothes and linen, and a sticky substance on the floor. The bathroom in this room had paper on the floor, a toilet with thick black debris, a shower floor covered with scum, and a sink with brown stains. The resident in this room expressed dissatisfaction with the frequency and quality of cleaning. Interviews with housekeeping and nursing staff confirmed that cleaning procedures were not consistently followed, with staff acknowledging the need for better cleaning of corners, removal of damaged mats, and immediate cleaning of spills. The facility's cleaning policy outlined specific steps for disinfecting and cleaning resident rooms and restrooms, but observations indicated these procedures were not being adhered to, resulting in unsanitary conditions in both common and resident-specific areas.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer scheduled and as-needed pain medications per the physician's orders for a resident, resulting in uncontrolled pain and emotional distress. The resident, who had a history of oral cancer and related pain, was admitted to the facility with a prescription for Oxycodone to manage his pain. However, upon review, it was found that the resident did not receive his pain medication for 17 hours after his last dose, leading to significant discomfort and distress. The resident's clinical records and nurse progress notes revealed multiple instances where pain medication was either not administered on time or withheld without proper justification. On one occasion, the resident's pain medication was not available due to a pharmacy issue, and on another, it was withheld due to undocumented behaviors. The resident expressed feelings of helplessness and frustration due to the lack of timely pain management, which was corroborated by complaints made to the state agency complaint hotline. Interviews with the Director of Nursing and the resident highlighted the facility's failure to adhere to its own policies on medication administration and pain management. The Director of Nursing acknowledged that behaviors should not justify withholding pain medication and that non-pharmacological interventions should have been attempted. The resident ultimately left the facility against medical advice due to inadequate pain management, further emphasizing the severity of the deficiency.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of employee-to-resident abuse to the State Agency for one resident, resulting in a deficiency. The incident involved a resident who was allegedly attacked by a female staff member, with the complainants reporting that the resident was slapped on the arm several times. Despite the complaints being reported to the state complaint hotline, the facility did not submit a Facility Reported Incident (FRI) for the allegation. The Nursing Home Administrator (NHA) was notified of the allegation but concluded that the incident did not occur and, therefore, did not report it to the state agency. The resident involved was admitted to the facility with multiple diagnoses, including malignant neoplasm of the mouth, dysarthria, and generalized anxiety disorder, among others. The resident was cognitively intact and required limited assistance with activities of daily living. The facility's policy required the Administrator or designee to report all alleged violations involving abuse to the State Agency within specified timeframes, depending on the severity of the allegation. However, the NHA stated that they were instructed not to report the incident, leading to a failure in compliance with the facility's policy and state regulations.
Failure to Address Critical Lab Findings and Delay in Treatment
Penalty
Summary
The facility failed to address changes in laboratory findings in a timely manner for a resident, resulting in significant critical laboratory values, delay in treatment, and hospitalization. The resident, who had a history of atrial fibrillation, breast cancer, diabetes, heart attack, hypertension, Covid-19, and anemia, was observed with mild edema in both lower legs and reported feeling weak, dizzy, and short of breath. Despite these symptoms and critical lab results indicating severe anemia, there was no change in the resident's plan of care or implementation of interventions to address the decreased iron levels. The resident's electronic medical record showed that their iron supplement was discontinued in July, and subsequent lab results in July indicated a decrease in hemoglobin and iron levels. However, there was no evidence of a change in the plan of care or involvement of a dietitian to address the low iron levels. The resident experienced symptoms of anemia, such as shortness of breath and dizziness, but the facility did not take timely action to address these issues. The Director of Nursing and Physician D were unable to provide a satisfactory explanation for the lack of timely intervention. The resident was eventually sent to the hospital after experiencing critical symptoms and lab results, where they were diagnosed with anemia, fluid overload, and acute kidney injury, and received a blood transfusion. The facility's policy on acute change in condition was not followed, contributing to the delay in treatment and hospitalization.
Improper Storage of Narcotic Medication
Penalty
Summary
The facility failed to ensure the proper storage of a narcotic medication for a resident, identified as R103, which potentially resulted in a missed dose, medication waste, and misappropriation. The resident was admitted with multiple diagnoses, including malignant neoplasm of the mouth, chronic kidney disease, and generalized anxiety disorder, and was cognitively intact, requiring limited assistance with daily activities. The resident was on a scheduled and PRN pain regimen, which included Oxycodone HCl, a controlled drug. On a specific date, the resident's medication was not delivered, and the pharmacy was contacted. Subsequently, a physician's order was sent, and the resident was administered one 5mg tablet of Oxycodone at 9:30 am. However, the Pyxis record showed that two 5mg Oxycodone tablets were signed out by an LPN, although only one tablet was administered. During an interview, the LPN stated that the extra tablet was pulled from the backup supply for the next dose or shift. The Director of Nursing (DON) confirmed that it was not standard practice to pull and store extra narcotics for future use, and narcotics should be signed out at the time of administration. The facility's policy on medication storage emphasized that medications should be stored safely and securely, accessible only to authorized personnel.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident with severe cognitive impairment, resulting in the resident exiting the facility without staff knowledge. The resident, who had diagnoses of Dementia and Alcohol Dependence with Alcohol-Induced Persisting Dementia, was last observed at a bingo event on the brown unit at 8:45 p.m. Staff noticed the resident was missing during rounds while passing medications. Despite a thorough search of the entire building, the resident could not be located, and the administrator, DON, and physician were notified. The resident returned to the facility the next morning, accompanied by a police officer, with empty alcohol bottles and unopened beer cans. The resident was confused but demonstrated how they exited the building. Interviews with staff revealed that the resident was last seen on the brown unit and was reported missing at 9:40 p.m. The Nursing Home Administrator confirmed that the resident exited through the main elevator near the receptionist desk. The facility's policy on elopement was reviewed, which stated that residents with cognitive loss who leave without authorization are considered an elopement risk.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R53), resulting in the potential for skin breakdown and infection. On two separate occasions, surveyors observed that R53's room had a strong urine smell, and the resident's brief was heavily saturated with urine. The first observation occurred on 2/27/24 at 11:52 a.m., and the second observation was on 2/29/24 at 8:13 a.m. In both instances, the resident's bed pad was also soiled. Interviews with CNAs and the LPN confirmed that R53 was not being checked and changed every two hours as required by the care plan and facility policy. R53 was admitted to the facility with diagnoses including Dementia and Atopic Dermatitis. The care plan for R53 specified that the resident should be checked and changed at least every two hours during the day. However, observations and staff interviews revealed that this protocol was not being followed. CNA D reported that R53 was last checked and changed at 7 a.m. and 12 p.m. on 2/27/24, while CNA E reported that R53 was changed for the first time that morning on 2/29/24. The Director of Nursing confirmed that incontinent residents should be checked and changed every two hours and as needed, which was not adhered to in R53's 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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