The Villa At Green Lake Estates
Inspection history, citations, penalties and survey trends for this long-term care facility in Orchard Lake, Michigan.
- Location
- 6470 Alden Dr, Orchard Lake, Michigan 48324
- CMS Provider Number
- 235489
- Inspections on file
- 32
- Latest survey
- October 8, 2025
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at The Villa At Green Lake Estates during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls suffered multiple injuries, including facial fractures and loss of consciousness, after falling on an unsecured staircase and from bed. The facility failed to implement required safety interventions such as a perimeter mattress and soft helmet, did not adequately document or report incidents, and did not communicate with the resident's POA regarding care decisions or falls.
A resident with multiple medical conditions did not receive physician-ordered lab tests, including UA, C&S, CBC, and BNP, due to the facility's failure to process and arrange for the tests as required by policy. The omission was discovered only after the resident was transferred to the hospital, and review confirmed that no lab results were present in the medical record for the ordered tests.
A resident with multiple pressure ulcers and significant care needs was not provided with individualized interventions for skin protection, as required by facility policy. Instead, only general monitoring and treatment measures were documented in the care plan, despite the presence of several stage three and four wounds. The DON confirmed that nurses were responsible for implementing skin management interventions but did not provide further explanation for the lack of individualized care.
A resident with severe cognitive impairment, developmental delay, and a history of falls was not provided with adequate supervision or individualized interventions to prevent falls, despite clear documentation of high risk and non-compliance. The care plan lacked specific strategies for increased monitoring, resulting in an unwitnessed fall with significant injuries that required hospital transfer.
Two residents developed or experienced worsening pressure ulcers due to the facility's failure to conduct timely and accurate skin assessments, document and report skin impairments, and implement effective interventions. One resident suffered a medical device-related wound from a Life Vest that was not properly monitored or addressed, while another developed multiple advanced-stage pressure ulcers that were not identified by staff until noted by a wound care consultant. The facility did not follow its own policies for skin inspection and documentation, leading to delayed recognition and treatment of pressure injuries.
An LPN was found with an opened, undated Humalog (insulin) pen and five loose, unidentifiable pills in a medication cart. The LPN could not explain the lack of dating or the presence of loose pills. Interviews with the unit manager and DON confirmed that facility policy requires opened insulin to be dated and medications to be properly stored, but these procedures were not followed.
A resident receiving hospice care, with diagnoses including dementia and Alzheimer's disease, experienced inconsistent and infrequent hospice nurse and aide visits. The facility provided unclear documentation of hospice staff schedules and lacked a facility-initiated care plan for hospice services. Staff interviews revealed uncertainty about who was responsible for monitoring hospice service provision, resulting in uncoordinated care.
Surveyors identified that 26 rooms did not meet the minimum 80 square feet per resident requirement for multiple occupancy rooms, with each room measuring approximately 148 to 149 square feet for two residents. Residents interviewed did not express dissatisfaction with room size, and the administrator reported no plans to expand or convert these rooms.
A resident reported multiple missing personal items and did not receive follow-up or resolution from facility staff or administration, as concerns were not documented unless a formal grievance was filed. Additionally, several residents expressed ongoing dissatisfaction with laundry services and a lack of effective response to their concerns. The facility's practice of only documenting formal grievances did not align with its policy requiring all grievances to be tracked and resolved.
A resident with severe cognitive impairment and wandering behaviors was found with unexplained bruises on two occasions. Staff documented the injuries but did not report them to the Administrator or conduct required investigations, despite facility policy mandating immediate reporting and investigation of injuries of unknown origin. The Administrator confirmed that these incidents were not brought to their attention, resulting in a failure to comply with reporting and investigation protocols.
A resident with multiple serious diagnoses, including acute respiratory failure and dementia, was admitted to hospice services, but the facility did not develop its own care plan for hospice or document coordination with the hospice provider. The DON confirmed that such a care plan should have been created, in accordance with facility policy requiring comprehensive, person-centered care planning.
A resident with multiple chronic conditions did not receive daily dressing changes for a skin tear as ordered, despite the TAR being marked as completed each day. Observation and interview revealed the dressing had not been changed for several days, and the DON confirmed the documentation did not match the actual care provided.
Two residents were not treated in a dignified manner when one was transported in a geri-chair facing backward while being pulled forward by a CNA, and another was described by a CNA as 'moody' and sleeping much of the day without appropriate context or sensitivity. The DON confirmed that such actions do not align with facility expectations for resident dignity.
Three residents experienced inadequate supervision and lack of effective interventions, resulting in one resident eloping from the facility, another repeatedly entering other residents' rooms and experiencing multiple falls, and a third resident having a fall that was not properly assessed or reported. Staff failed to document required checks and interventions, and care plans were not updated to reflect incidents, despite facility policies requiring these actions.
A resident was prescribed Ivermectin for possible scabies, but the order lacked a stop date, resulting in the medication being administered daily beyond the intended treatment period. The NP was unaware the medication continued, and the DON acknowledged a stop date should have been included, as required by the facility's antibiotic stewardship policy.
A resident's funds were misappropriated when a CNA accepted the resident's debit card and used it for unauthorized withdrawals and purchases, exceeding the amount authorized by the resident. The resident had not left the facility except for hospital visits and reported the issue after noticing suspicious transactions on her bank statement. The CNA's actions violated facility policy regarding the protection of resident property.
Two residents were affected by improper implementation and documentation of transmission-based precautions (TBP): one had an active order for contact isolation due to scabies but lacked required signage and PPE outside their room, while another had TBP signage and PPE present without any corresponding physician's order. Facility staff were either unaware of the need for TBP or unable to provide justification, and the facility's policy did not clarify the requirement for physician orders for TBP.
A resident in an LTC facility sustained a shoulder injury requiring stitches after falling out of bed when left unattended by a CNA during the night shift. The CNA, unfamiliar with the resident's needs and overwhelmed by being short-staffed, left the resident in an unsafe position. The resident, who was on a blood thinner, required maximal assistance for bed mobility, which was not provided, leading to the fall.
The facility failed to implement effective discharge planning for two residents, leading to psychosocial harm. One resident was transferred without family approval or notification to the receiving facility, while another resident's request to move was not followed up on, leaving them frustrated. The facility did not involve families in planning or communicate effectively with receiving facilities.
A facility failed to provide written transfer notification to a resident's representative and the Ombudsman, as required for facility-initiated transfers. The resident, with severe cognitive impairment and language barriers, was transferred without the representative's involvement in the discharge plan. The representative was only informed via phone the day before the transfer, unaware of the new facility's location. Interviews confirmed the facility did not follow its policies for discharge planning and notification.
The facility failed to properly document and administer controlled substances for two residents, leading to discrepancies between the Medication Administration Record (MAR) and the Medication Monitoring/Control Record. One resident's alprazolam administration was not consistently documented, and another resident found pills in their bed despite records indicating they had been administered. Interviews with the DON confirmed that medications should be signed out and observed as taken, but the facility could not reconcile the discrepancies.
The facility failed to properly store and label medications in two medication carts. On the third floor, an RN found undated insulin pens in the cart, while on the first floor, a nurse discovered insulin pens without dates or resident labels. Additionally, various medications and treatment supplies were improperly stored together. The DON acknowledged the issue, emphasizing that maintaining cleanliness was a shared responsibility among nurses.
The facility failed to promptly respond to call lights for three residents, leading them to contact the receptionist for assistance. Residents with conditions such as Multiple Sclerosis, bladder dysfunction, and stroke experienced delays, with one resident waiting up to an hour. The DON acknowledged the issue, noting the facility's outdated call light system and the policy requiring responses within 5 minutes.
The facility failed to ensure residents' rights to private and confidential mail delivery. Several residents reported concerns about not receiving their mail timely and unopened. Interviews with the Administrator and Admissions Director revealed inconsistencies and a lack of awareness in the facility's mail handling practices.
The facility failed to ensure residents and visitors had access to previous survey results, as guaranteed by federal and state laws. During a resident council interview, none of the 11 residents knew where to access the survey binder, and the receptionist was also unaware. The Administrator confirmed that the survey binder had been removed temporarily and was not put back, leading to residents and visitors being uninformed of deficiencies identified in the facility.
The facility failed to maintain sanitary conditions in the kitchen and ensure food items were labeled, dated, and discarded when expired. Personal items were stored on food bins, a scoop was improperly stored in rice, and the dish machine was non-functional without proper sanitization monitoring. Expired food items were found in storage, and equipment cleaning logs were outdated, posing health risks to residents.
The facility failed to document, investigate, track, and resolve grievances from the resident council. Interviews and record reviews revealed that concerns such as staff phone usage, delayed call light responses, and missing personal items were not followed up on, despite the facility's policy requiring immediate submission and resolution of grievances.
The facility failed to provide timely incontinence care for a resident and routine showers for another. One resident was left without incontinence care for nearly two hours despite reporting discomfort, and another reported receiving only two showers since admission. The facility's policies for incontinence care and shower frequency were not followed.
The facility failed to ensure an environment free from accident hazards regarding the storage of blood sugar testing lancets in a medication cart. Approximately 40 lancets were found in an uncovered container on top of the cart, with no nurse in view. The DON confirmed the improper storage and directed the nurse to place the container inside the cart. The facility's Medication Storage Checklist did not address the storage process for lancets before use.
The facility failed to ensure appropriate consent, assessment, and physician orders for the use of assist bars/rails for eight residents, posing a potential risk to all 76 residents. Interviews revealed a lack of clear responsibility and documentation, contrary to the facility's guidelines.
The facility failed to provide sufficient nursing staff on the first floor, resulting in delayed medication administration and unmet care needs. Multiple residents reported issues with call light response times, cold food, and infrequent showers. An agency nurse admitted to being overwhelmed, and the DON acknowledged the staffing concerns but had not added additional staff. Facility policies on staffing and medication administration were not followed.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with conditions requiring such measures, and also failed to maintain proper linen storage practices. Observations revealed a lack of EBP signs, PPE availability, and improper storage of personal care items with clean linens.
A resident reported being accused of drug-seeking behavior by an LPN in front of others, affecting their treatment by staff. The resident's care plan included pain management, but the LPN's progress notes contained subjective and inappropriate comments. The DON acknowledged the inappropriateness of the notes, and the LPN admitted to subjective charting but denied personal issues with the resident.
A resident with multiple diagnoses, including pneumonia and lung cancer, was found self-administering an albuterol inhaler without an assessment or care plan in place. Despite having intact cognition, the facility failed to document the resident's ability to self-administer medication, as confirmed by the DON and other staff.
A resident with a history of physical abuse was told by the Administrator they would have to change rooms to avoid a particular LPN, despite the resident's attachment to their current room as a safe place. The Administrator did not consider using other nurses to accommodate the resident's preference, contradicting the resident's care plan and facility policy on resident rights.
The facility failed to ensure timely medication administration and proper physician notification for a resident. Several residents reported receiving medications late, and one resident did not receive their 9:00 AM medications on time. The DON acknowledged the issue, but the facility's process for late medication administration was not followed, and staffing levels were inadequately managed.
The facility failed to implement necessary interventions for pressure ulcer prevention for a resident and did not complete required skin assessments for another resident. One resident was observed without the ordered low air loss mattress and heel offloading boots, while another resident was left without incontinence care for an extended period and lacked documented skin assessments for two months.
A facility failed to document intermittent catheterization for a resident with quadriplegia and bladder dysfunction. The resident experienced discomfort due to delayed catheterization, and significant amounts of urine obtained were not recorded. The Director of Nursing confirmed the necessity of such documentation.
A resident was prescribed Seroquel without adequate indication, appropriate consent, or clinical rationale. The social service assessment was overdue, and the care plan lacked specific details. Conflicting opinions on the resident's competency were noted, and the facility's policy on psychotropic medication management was not followed.
The facility failed to provide the required 80 square feet per resident in multiple resident rooms for 26 out of 42 rooms. Despite no resident complaints, the rooms did not meet the regulatory space requirements.
Failure to Prevent Falls and Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to properly assess for safety, implement timely and effective interventions, and provide adequate supervision to prevent accidents for a resident identified as high fall risk, a wanderer, and with severe cognitive impairment. The resident had a history of falls with injury and was completely dependent on staff for mobility and transfers. Despite these risks, the resident experienced multiple falls, including incidents on a staircase that resulted in multiple facial fractures, a laceration requiring closure, loss of consciousness, hospitalization, and unnecessary pain. The facility did not ensure the environment was free from accident hazards, as the stairwell was open and accessible to cognitively impaired residents without any deterrents in place at the time of the incidents. Interviews and record reviews revealed that the facility did not follow the resident's care plan, which included interventions such as a perimeter mattress and a soft helmet. The resident was observed without a perimeter mattress or helmet at the time of the falls, and staff were unable to explain why these interventions were not in place. Documentation of the incidents was incomplete or delayed, with missing progress notes, lack of vital sign documentation, and late entries in the medical record. The facility also failed to notify the State Agency of the incidents involving major injuries in a timely manner. Additionally, the facility did not involve the resident's Power of Attorney (POA) in care decisions or care planning, including the initiation of hospice services and notification of falls. The POA reported not being informed of significant events, including additional falls, and expressed concerns about the lack of communication and coordination with the facility. The combination of inadequate supervision, failure to implement care plan interventions, lack of environmental safeguards, and poor communication contributed to the resident's repeated injuries and decline.
Removal Plan
- Nurse management team completed new fall risk assessments for all like residents.
- The interdisciplinary team updated all current resident's plans of care based on new risk assessments.
- Stop sign barrier banners have been placed at the entrance way of the stair well on ascending and descending sides to impede resident usage.
- Measurements for the stairwell have been taken by the Maintenance Director to research and implement a more permanent solution.
Failure to Obtain Ordered Laboratory Services
Penalty
Summary
The facility failed to obtain laboratory services as ordered by a physician for one resident during their stay. The resident, who had diagnoses including intellectual disabilities, pneumonia, and anxiety disorder, was admitted following hospitalization for a left ankle fracture. A physician order was placed for urinalysis (UA) with culture and sensitivity (C&S), complete blood count (CBC), and B-type natriuretic peptide (BNP) testing to rule out infection and monitor health status. However, review of the electronic medical record showed no lab results for these tests, and an interdisciplinary team note indicated no new labs had been completed. The facility's protocol required staff to process test requisitions and arrange for tests, but this was not followed. The deficiency was confirmed through interviews and record review, including an interview with the DON, who acknowledged that the lab draw was missed and the facility was not compliant with its own lab policy during the resident's stay. The issue was identified only after the resident was transferred to the hospital following a fall. The facility's own review confirmed that the required laboratory services were not provided as ordered between the dates in question.
Failure to Implement Individualized Skin Protection Interventions
Penalty
Summary
Facility staff failed to follow their own policy regarding the implementation of individualized interventions for skin protection for a resident with multiple pressure wounds. The resident, who was admitted with diagnoses including paraplegia, pressure ulcers, and contractures, required staff assistance for all activities of daily living. Upon review, the resident was found to have numerous wounds, including stage three and four pressure ulcers on various parts of the body. Despite these findings, the care plans only included general interventions such as monitoring skin during care and notifying nurses of changes, as well as evaluating and treating per physician orders. No additional individualized interventions or care plans were implemented to address the resident's specific skin management needs, as required by facility policy. The facility's Skin Protection Guideline policy mandates the identification of at-risk residents and the prompt implementation of individualized interventions to prevent and treat skin breakdown. However, the care plans for this resident did not reflect individualized strategies or a turning and repositioning schedule, despite the presence of multiple wounds. When questioned, the DON acknowledged that nurses were responsible for implementing wound and skin management interventions but did not provide further explanation or documentation regarding the lack of individualized care plans and interventions for the resident.
Failure to Provide Adequate Supervision and Resident-Specific Fall Prevention
Penalty
Summary
A deficiency was identified when the facility failed to provide adequate supervision and implement resident-specific interventions to prevent falls for a resident with a known history of falls, severe intellectual disabilities, developmental delay, and non-compliance with care. The resident was admitted with multiple risk factors, including a recent joint replacement, non-weight bearing status, impulsiveness, combativeness, and inability to follow commands. Documentation from the transferring hospital and facility records consistently noted the resident's high fall risk, cognitive impairment, and need for 24/7 supervision and assistance. Despite these documented risks, the facility's care plans and interventions did not reflect the level of supervision or specific interventions required for the resident's safety. The care plans included general fall prevention strategies such as keeping the bed in a low position, encouraging hydration, and providing non-skid footwear, but did not address the resident's inability to comply with instructions or the need for increased monitoring. Staff and the DON acknowledged the resident's non-compliance and impulsiveness, but interventions such as increased monitoring were only communicated verbally and not documented or clearly defined in the care plan. The facility's policy required individualized assessment and implementation of adequate supervision, but this was not effectively carried out for this resident. The deficiency resulted in an unwitnessed fall, during which the resident sustained significant injuries, including a head laceration, facial bruising, and bleeding, necessitating transfer to the hospital for a higher level of care. The fall occurred despite earlier staff assistance and placement of the call light within reach. The facility's investigation confirmed that interventions for increased observation and supervision were not documented in the care plan, and the root cause analysis did not provide a clear explanation for the failure to prevent the fall.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. One resident, who wore a Life Vest (a wearable cardioverter defibrillator), reported that the vest was too tight and caused a painful wound on his torso. Despite the resident's complaints and visible skin impairment, there was no documentation of a skin assessment or treatment for the wound upon admission, and the care plan did not address the medical device-related wound or include interventions for monitoring skin under the vest. Weekly skin checks were ordered, but the vest was only removed for showers, limiting the ability to assess and protect the skin. The wound was eventually identified as a full-thickness pressure injury with slough and black, scab-like areas, but documentation and intervention were delayed, and there was no evidence of timely communication with the vest provider for a better fit. Another resident, who was quadriplegic and required total assistance for care, developed multiple pressure ulcers, some of which were acquired in the facility. The clinical record showed a lack of timely and accurate documentation of skin impairments, with wounds first identified at advanced stages (Unstageable or Stage 3) by a wound care consultant. There were significant gaps in weekly skin observations, and new wounds were not documented by facility staff prior to consultant identification. The care plan included general monitoring instructions, but there was no evidence that staff consistently monitored, documented, or reported changes in skin condition as required. Interviews with the DON and ADON revealed a lack of clear oversight and accountability for wound care, with inconsistent skin checks and delayed identification of wounds. The facility's own policy required daily skin inspections and immediate reporting of any signs of breakdown, but these procedures were not followed. The deficiencies resulted in the development and worsening of pressure ulcers for both residents, with inadequate documentation, assessment, and intervention throughout their stays.
Failure to Properly Date and Store Medications in Medication Cart
Penalty
Summary
Surveyors observed that an opened Humalog (insulin) pen was found undated in the top drawer of a medication cart during a medication pass with an LPN. The LPN confirmed the insulin pen was open and should have been dated but was unsure why it was not. Additionally, five loose, unidentifiable pills were found in the same medication cart drawer. The LPN, who identified as a new nurse, could not explain how the loose pills ended up in the drawer and stated that management was checking medication carts weekly. Interviews with the unit manager and the Director of Nursing confirmed that insulin should be dated upon opening and that staff are expected to follow facility procedures for medication storage and handling. Facility policy requires that all medications be stored in properly labeled containers, with opened medications such as insulin dated and assigned a new expiration date. The presence of undated insulin and loose pills in the medication cart indicated a failure to adhere to these established protocols.
Failure to Coordinate and Monitor Hospice Services
Penalty
Summary
The facility failed to ensure coordinated hospice service visits for a resident who was admitted with multiple diagnoses, including dementia, acute respiratory failure, high blood pressure, and Alzheimer's disease, and who was enrolled in hospice services. Record review showed significant gaps in hospice nurse and aide visits, with only three nurse visits documented over a one-month period and inconsistent aide visits, including a complete absence of aide visits for one month. The hospice visit schedule provided by the facility was unclear, lacking information on the discipline of staff making the visits, and was difficult to read. Interviews with facility staff revealed a lack of clarity regarding who was responsible for monitoring hospice staff visits. The social worker was unable to identify who ensured hospice services were provided as scheduled and did not follow up with this information. The DON acknowledged that a facility-initiated care plan for hospice services should have been in place but was not. Review of the facility's hospice policy confirmed the responsibility to coordinate care and maintain updated care plans, which was not met in this case.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in multiple occupancy rooms for 26 out of 42 resident rooms, as determined through observation, interviews, and review of facility records. Measurements of the affected rooms showed that each had approximately 148 to 149 square feet for two residents, which is less than the required 160 square feet total (80 per resident). Interviews with residents revealed no complaints regarding room size, and there was no indication that resident health or safety was affected by the room dimensions. The facility administrator confirmed there were no current plans to expand or convert the rooms to singles, only plans for aesthetic changes.
Failure to Maintain Effective Grievance Resolution Process
Penalty
Summary
The facility failed to maintain an effective grievance resolution process, as evidenced by the lack of prompt and documented responses to resident concerns. One resident, who was cognitively intact, reported multiple instances of missing personal items, including clothing, a purse, a wallet, a significant amount of money, and a blanket. The resident stated that she had reported these issues to both a staff member and the Administrator, but did not receive any follow-up or information regarding what actions, if any, were taken to address her concerns. The Administrator confirmed that unless a formal grievance form was completed, concerns were not documented or formally investigated, and no records existed of any investigation or follow-up for this resident's reported missing items. Additionally, during a group interview with eight residents who attended resident council meetings, seven expressed ongoing dissatisfaction with the facility's handling of laundry, specifically regarding the return of their clothing. Residents reported that labeled clothing often did not return from laundry, and issues persisted for a long time without resolution or explanation from the facility. Residents also indicated a lack of clarity and confidence in the grievance process, with some stating that expressing concerns did not lead to resolution and that there was confusion about how to file grievances. A review of the facility's grievance policy revealed that all grievances, whether expressed orally or in writing, should be tracked, investigated, and resolved, with the resident kept informed of progress. The policy also required the Grievance Officer to maintain a log of all grievances. However, the facility's practice, as described by the Administrator, was to only document and investigate concerns if a formal grievance was filed, resulting in a lack of documentation, tracking, and resolution for concerns that were not formally submitted. This practice did not align with the facility's written policy and led to unresolved resident grievances.
Failure to Report and Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin to the Administrator/Abuse Coordinator for a resident with severe cognitive impairment and wandering behaviors. The resident, who had diagnoses including metabolic encephalopathy, dementia with behavioral disturbance, and Alzheimer's disease, was observed wandering into other residents' rooms, attempting to get into their beds, and was unable to provide clear explanations for her actions or injuries. On two separate occasions, the resident was found with unexplained bruises: one on the back of her right leg and another on her left eyebrow. In both cases, the source of the injuries was not witnessed, and the resident could not describe what had happened. A review of the clinical record and incident reports revealed that while the injuries were documented by staff, there was no associated investigation conducted or provided for either incident. The facility's policy required that injuries of unknown origin be immediately investigated and reported to the Administrator and, if necessary, to the State Agency. However, the Administrator confirmed that these incidents were not reported to him, and no further investigation was initiated as required by facility policy. Interviews with the Administrator/Abuse Coordinator confirmed that the protocol was not followed, as injuries of unknown origin should have been reported to initiate an investigation and determine if further reporting to the State Agency was necessary. The lack of reporting and investigation for these injuries constituted a failure to comply with the facility's own policy and regulatory requirements regarding the timely reporting and investigation of suspected abuse, neglect, or injuries of unknown origin.
Failure to Develop Integrated Hospice Care Plan
Penalty
Summary
The facility failed to develop and implement an integrated hospice care plan for a resident who was admitted with acute respiratory failure, high blood pressure, Alzheimer's disease, and dementia, and who was receiving hospice services. Although the hospice company had developed a care plan, the facility's own care plans did not include a plan for hospice services or outline coordination between the facility and the hospice provider. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that a facility care plan indicating hospice status and coordination should have been in place. Review of facility policy also indicated the requirement for a comprehensive, person-centered care plan with measurable objectives and timeframes to meet the resident's identified needs.
Failure to Complete and Accurately Document Dressing Changes
Penalty
Summary
A deficiency occurred when a resident with a history of diabetes, Parkinson's disease, and heart disease, who was cognitively intact, did not receive dressing changes for a skin tear as ordered. The resident was observed with a gauze dressing on his left wrist dated five days prior, and he reported that it had been a couple of days since the dressing was last changed. The treatment order specified that the wound should be cleansed, antibiotic ointment applied, and a dry dressing placed every day shift. Record review showed that the Treatment Administration Record (TAR) was marked as completed daily, indicating the dressing change was performed, even though the date on the dressing and the resident's statement suggested otherwise. The Director of Nursing confirmed the discrepancy between the TAR documentation and the actual date on the dressing, acknowledging that the TAR should only be marked as completed after the treatment is performed. This failure resulted in the resident not receiving care as ordered and documented.
Failure to Ensure Dignified Treatment During Resident Transport and Communication
Penalty
Summary
The facility failed to ensure that two residents were treated in a dignified manner, as required by policy. One resident was observed being transported in a geri-chair by a CNA who pulled the chair forward while the resident was facing backward, which is not an appropriate or respectful method of transport. Another resident was discussed by a CNA, who described the resident as sometimes being 'moody' and sleeping throughout the morning and into the afternoon, without further context or sensitivity. The DON confirmed that wheelchairs should not be pulled in a forward motion with the resident facing backward and that staff are expected to treat residents with dignity. The facility's policy emphasizes care that promotes dignity, respect, and individuality for each resident.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent accidents for three residents, resulting in incidents of elopement, repeated entry into other residents' rooms, and a fall without proper assessment or follow-up. One resident with a history of adjustment disorder, dementia, and severely impaired cognition was identified as an elopement risk and had demonstrated exit-seeking behaviors, including attempting to leave the floor and pushing on doors. Despite this, the only intervention in place prior to the resident's elopement was staff awareness of the wander risk. The resident was able to exit the building, traverse stairwells, and reach the parking lot before being intercepted by staff, indicating a lack of effective supervision and failure to implement additional interventions despite known risks. Another resident with severe cognitive impairment and a history of wandering was observed repeatedly entering other residents' rooms, sometimes attempting to get into their beds. The care plan for this resident included 30-minute checks after wandering incidents, but there was no documentation of these checks or of the resident's behaviors in the clinical record. Staff interviews revealed a lack of awareness and inconsistent documentation regarding the resident's wandering and the required interventions, and the resident experienced multiple falls, including one resulting in a head injury and hospital transfer. A third resident, with intact cognition but significant mobility assistance needs, experienced a fall in their room. The incident was documented as a behavior note rather than a fall, and there was no evidence of a post-incident assessment, incident report, or notification to the resident's physician or legal guardian. The care plan was not updated to reflect the incident, and staff interviews confirmed that the facility's process for fall events was not followed. Facility policies required identification, evaluation, implementation, and monitoring of interventions to reduce accident risks, but these processes were not consistently applied for the residents involved.
Failure to Include Stop Date for Antibiotic Therapy
Penalty
Summary
A nurse practitioner prescribed Ivermectin for a resident to treat possible scabies, with specific administration days outlined in the order. However, the order did not include a stop date, and as a result, the medication continued to be administered daily beyond the intended treatment period, except for a few days when the resident refused the medication. The medication was only discontinued after a review of the records revealed the ongoing administration. During interviews, the nurse practitioner stated they were unaware the medication had not been stopped after the intended treatment days and confirmed it should not have been given beyond that period. The Director of Nursing acknowledged that a stop date should have been included in the order. The facility's infection prevention and control manual specifies that antibiotic stewardship includes documenting the duration of therapy and ensuring discontinuation when antibiotics are no longer needed.
Failure to Prevent Misappropriation of Resident Funds by CNA
Penalty
Summary
A facility failed to protect a resident from misappropriation of funds when a Certified Nurse Aide (CNA) accepted and used the resident's debit card for unauthorized transactions. The resident, who had not left the facility except for hospital visits since admission, noticed suspicious transactions on her bank statement and reported that she had only given her debit card to one CNA to withdraw a specific amount of money. The CNA withdrew more money than authorized and made additional point-of-sale purchases unrelated to the resident's requests, including transactions near the CNA's home and not near the facility. The facility's investigation included interviews with the resident, the involved CNA, and another staff member, as well as a review of bank statements and facility policies. The resident consistently denied giving her card to anyone other than the implicated CNA. The CNA's actions were found to be in violation of the facility's code of conduct and policy regarding the misappropriation of resident property, which defines such misappropriation as the wrongful use of a resident's belongings or money without consent.
Failure to Ensure Proper Implementation and Documentation of Transmission-Based Precautions
Penalty
Summary
The facility failed to ensure proper infection control practices regarding transmission-based precautions (TBP) for two residents. One resident with an active physician's order for contact isolation due to scabies was observed multiple times without any TBP signage or an isolation caddy with personal protective equipment (PPE) on the door to their room. This lack of visible precautions was noted on several occasions, despite the ongoing order for contact isolation. Another resident was observed with both contact and droplet precaution signage and an isolation caddy on their door, but a review of their physician's orders revealed no active or discontinued orders for TBP. When questioned, the assigned nurse was unaware of the reason for the precautions and did not follow up. The facility's Director of Nursing later confirmed that the first resident should no longer have been on TBP and the order should have been discontinued, while the second resident should have had an order and indication for TBP. The facility's policy referenced CDC guidelines but did not specify whether a physician's order was required for TBP.
Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent a fall with injury for a resident, resulting in actual harm when the resident required stitches to their shoulder after falling out of bed. The incident occurred when the resident, who was cognitively intact and had a history of stroke, heart failure, arthritis, anxiety, and depression, was left unattended by a Certified Nurse Aide (CNA) during the night shift. The resident was positioned on their side unsupported and rolled out of bed, sustaining a laceration that required 11 stitches. The resident was on a blood thinner at the time, increasing the risk of bleeding. The CNA, who was recently hired and unfamiliar with the resident, reported being overwhelmed due to being short-staffed and having to care for more residents than usual. The CNA left the resident unattended to gather supplies, believing the resident could hold their weight. The bed was positioned at mid-height and not lowered to the ground, which contributed to the fall. The CNA did not review the resident's care plan or any care designation guide, which indicated the resident required maximal assistance for bed mobility and was dependent on a full mechanical lift for transfers. The facility's policy on fall evaluation and safety guidelines was not adequately followed, as the resident was left in an unsafe position, leading to the fall. The incident report and investigation revealed that the CNA had only one day of training on the hall and was not familiar with the resident's specific needs. The resident's care plan required assistance by staff to turn and reposition in bed, which was not adhered to, resulting in the fall and subsequent injury.
Inadequate Discharge Planning and Communication
Penalty
Summary
The facility failed to implement an effective discharge planning process for two residents, resulting in psychosocial harm. Resident R901, who had aphasia, a language barrier, and severe cognitive impairment, was discharged to a facility farther away from their family without the approval of their representative and without notifying the receiving facility. The discharge was initiated due to R901's wandering behavior and the facility's inability to provide adequate supervision. However, the facility did not involve R901's representative in the discharge planning process, nor did they provide an opportunity for discussion about the discharge plan, location, or appropriateness of the new facility for R901's care needs. The facility's social worker and interdisciplinary team did not engage with R901's family to develop a resident-specific discharge plan. The family was only informed of the transfer on the day it occurred, and the receiving facility was not notified in advance. R901 arrived at the new facility without personal belongings or medications, and the staff there were unaware of the transfer. The facility's discharge process lacked communication and coordination, leading to distress for R901's family, who were regular visitors and had not consented to the transfer. Resident R902 expressed dissatisfaction with their living situation and had requested assistance from the facility to transfer to another location. Despite the resident's intact cognition and clear communication of their desire to move, the facility did not follow up on the referrals sent to other facilities. The social worker did not provide updates to R902, and there was no evidence of further action taken to facilitate the transfer. This lack of follow-up and communication left R902 feeling frustrated and dissatisfied with their current living arrangements.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written transfer notification to a resident's representative and the Ombudsman, which is a requirement for facility-initiated transfers or discharges. The resident in question, identified as R901, was admitted to the facility after a hospital stay with diagnoses including aphasia, dementia, anxiety disorder, nutritional deficiency, and COPD. R901 had severe cognitive impairment and a language barrier, with their spouse appointed as the Durable Power of Attorney (DPOA). Despite these conditions, the facility did not provide the necessary written notice of transfer to the resident's representative or the Ombudsman. The facility's records showed that R901 was transferred to another facility due to the need for a more appropriate environment, as noted in a progress note. However, there was no evidence that the facility provided any written notices to R901's representative, nor did they involve the representative in developing a discharge plan. The representative was only informed via phone the day before the transfer, and they were not aware of the new facility's location, which was an hour away from their residence. This lack of communication and documentation was confirmed during interviews with the resident's spouse and daughter, who expressed their dissatisfaction with the process. Interviews with facility staff, including the social worker and the administrator, revealed that the facility did not follow its own policies regarding discharge planning and notification. The social worker admitted to not providing written notification, and the administrator acknowledged the concerns raised about the discharge process. The facility's policy requires a 30-day advance written notice for transfers or discharges, including specific information about the transfer, appeal rights, and contact information for relevant agencies, none of which were provided in this case.
Controlled Substance Documentation and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and administration of controlled substances for two residents, leading to discrepancies in medication records. For one resident, there were inconsistencies between the Medication Administration Record (MAR) and the Medication Monitoring/Control Record regarding the administration of alprazolam. The MAR indicated that the medication was given at specific times, but the Control Record did not document the removal of the medication from the supply, suggesting a lack of accountability for the controlled substance. Additionally, the facility was unable to provide the Control Records for certain dates, further highlighting the documentation issues. Another resident experienced a similar issue with the administration of controlled substances. A registered nurse expressed concerns about the administration and recording of medications, particularly controlled substances. The resident reported not receiving their pain medication, despite the controlled substance sheet indicating it had been signed out and administered. The resident later found two pills in their bed, which they believed were not their pain medication. A review of the resident's records revealed discrepancies between the doses signed out on the Control Record and those documented as given on the MAR. Interviews with the Director of Nursing (DON) confirmed that the facility's protocol requires medications to be signed out on the Control Record and marked as given on the MAR after being observed as taken. The DON acknowledged that medications should not be left for residents to take on their own and that any refusal should be documented. Despite these protocols, the facility was unable to provide additional documentation to reconcile the discrepancies between the Control Records and the MARs for the residents involved.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and treatment supplies in two of five medication carts, as observed during a survey. On the third floor, a Registered Nurse (RN) identified three insulin pens in the medication cart that lacked dates indicating when they were removed from refrigeration. The RN expressed uncertainty about how to proceed with these undated insulin pens, acknowledging that they should have been dated upon removal from the refrigerator. On the first floor, a review of the medication cart with a nurse revealed two insulin pens sealed with tamper-resistant tape, but without dates indicating when they were placed in the cart. Additionally, one of the pens lacked a label with a resident's name. The nurse was unable to identify when the pens were placed in the cart or the owner of the unlabeled pen. Further inspection of the cart revealed improper storage of various medications and treatment supplies, including rectal suppositories, topical lotions, creams, and shampoos stored alongside oral medications. The facility's Director of Nursing acknowledged awareness of the medication cart conditions and stated that maintaining cleanliness was the responsibility of all nurses.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to provide reasonable accommodation for resident needs by not promptly responding to call lights, affecting three residents. A complaint was received by the State Agency alleging that a resident had to wait for assistance for 45 minutes to an hour, leading to the involvement of the facility receptionist. Interviews and record reviews revealed that residents R800, R801, and R802 experienced delays in call light responses, prompting them to use personal cell phones to contact the receptionist for assistance. R800, diagnosed with Multiple Sclerosis and requiring extensive assistance with ADLs, expressed frustration over the delayed response times. R801, with a diagnosis of bladder dysfunction, diabetes, hypothyroidism, and chronic blood clots, reported that call lights could take up to 30 minutes to be answered, affecting their ability to receive timely meal deliveries. R802, who had a stroke resulting in left-sided paralysis, also resorted to calling the receptionist for basic needs like razors and water. The Director of Nursing (DON) acknowledged that nursing staff are educated to respond to call lights within 2-5 minutes, but the facility's outdated call light system does not allow for electronic tracking of response times. The DON was unaware that residents were contacting the receptionist due to unresponsive call lights and admitted that this was inappropriate. The facility's policy states that calls for assistance should be answered as soon as possible, but no later than 5 minutes, with urgent requests addressed immediately. The failure to adhere to this policy resulted in residents seeking alternative means to get assistance, highlighting a deficiency in the facility's response system.
Failure to Ensure Private and Confidential Mail Delivery
Penalty
Summary
The facility failed to ensure that residents' rights to private and confidential mail delivery were maintained. During a resident council interview, several residents expressed concerns about not receiving their mail timely and unopened. One resident showed an admission packet that included an authorization form allowing the facility to open certain types of mail, which raised concerns among other residents about the legality of this practice. The facility's policy on resident rights guarantees access to mail with privacy, and state law prohibits taking, holding, or destroying another person's mail. Interviews with the Administrator and the Admissions Director revealed a lack of awareness and inconsistency in the facility's mail handling practices. The Administrator admitted that mail should not be opened by staff and that residents should ask for help if needed. The Admissions Director acknowledged the admission agreement's verbiage but claimed it was a typo and was not responsible for the contract's contents. This inconsistency and lack of awareness led to the deficiency in maintaining residents' rights to private and confidential mail delivery.
Failure to Provide Access to Survey Results
Penalty
Summary
The facility failed to ensure that residents and visitors had access to previous survey results, which is a right guaranteed by federal and state laws. During a resident council interview with 11 residents, none were aware of where they could access the facility's survey binder or that anyone had discussed this with them previously. Additionally, the receptionist was unaware of the survey binders' location and the process for accessing them, despite signage indicating that such information was available upon request from the Administrator. The Administrator confirmed that the survey binder had been removed temporarily and was not put back, and the receptionist, who had been in their role for about three years, should have known about it. The facility's policy titled 'Resident Rights' guarantees residents the right to examine survey results. However, the facility did not adhere to this policy, as evidenced by the lack of awareness among residents and staff about the location and accessibility of the survey binders. The Administrator admitted that the survey binder had been removed temporarily and was not returned, leading to a situation where residents and visitors were uninformed of deficiencies identified in the facility. This failure had the potential to affect all residents residing in the facility.
Sanitary Conditions and Food Labeling Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and ensure food items were labeled, dated, and discarded when expired. During an initial tour of the kitchen, personal items were found stored on top of food storage bins, and a scoop was improperly stored inside a bin of rice. The high-temperature dish machine had been non-functional for about two weeks, and staff were using a hose in a bottle of bleach for sanitizing without proper monitoring or testing strips to ensure effective sanitization. Additionally, the ice machine cleaning log was outdated, and the machine had visible debris, while the juice machine had accumulated thick dust despite weekly servicing claims. The walk-in freezer and refrigerator temperature logs were not up-to-date, and expired food items, such as cottage cheese and pre-scooped ice cream, were found in storage. The facility's Certified Food Manager (CFM) confirmed these observations and acknowledged the lapses in monitoring and discarding expired food. The dish machine, which had been temporarily fixed, still failed to reach the required sanitizing temperature during a test run, indicating ongoing issues with the equipment. These deficiencies were observed and confirmed through interviews and record reviews, highlighting the facility's failure to adhere to the 2017 FDA Food Code standards. The lack of proper food storage, labeling, and equipment maintenance had the potential to affect all residents consuming food from the kitchen, posing significant health risks due to possible contamination and inadequate sanitization practices.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances from residents participating in the resident council were promptly documented, investigated, tracked, and resolved. During an interview with the Activity Director, it was revealed that some resident council minutes were damaged, and there was no documentation of follow-up on grievances. The Activity Director mentioned that concerns were being put on grievance forms since the last annual survey, but these forms were not provided for review by the end of the survey. Previous resident council minutes highlighted various concerns, including staff being on their phones, delayed call light responses, missing clothing, and inadequate housekeeping. However, there was no evidence of follow-up or resolution for these grievances. An interview with 11 residents confirmed that there was no follow-up on concerns discussed in previous resident council meetings. Residents reported ongoing issues with staffing, long response times to call lights, and missing personal items. The Administrator acknowledged the concern but could not provide further explanation. The facility's policy on grievances states that all grievances identified during the Resident Council meeting should be submitted immediately to the Grievance Official for investigation and resolution, with outcomes reported back to the Resident Council, which was not adhered to in this case.
Failure to Provide Timely Incontinence Care and Routine Showers
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R9) and routine showers for another resident (R56). Continuous observations on 5/6/24 revealed that R9 was left without incontinence care from 10:42 AM to 12:39 PM, despite reporting discomfort due to being wet. Certified Nursing Assistant (CNA 'V') did not check or provide incontinence care when interacting with R9. The Director of Nursing (DON) confirmed that incontinence care should be provided every two hours, which was not done for R9. R9's clinical record indicated a diagnosis of dementia and Alzheimer's disease, with a care plan requiring assistance with toileting and incontinence care after each episode, which was not followed. Additionally, resident council interviews revealed that multiple residents had concerns about not receiving showers or having to wait prolonged periods for toileting/incontinence care. R56 reported receiving only two showers since admission on 4/11/2024. The DON confirmed that showers should be documented in the electronic health record and on paper, but records showed R56 received only one shower and refused another, with no rationale for missed showers. The facility's policy encourages a minimum of two showers per week, which was not adhered to for R56.
Improper Storage of Sharps on Medication Cart
Penalty
Summary
The facility failed to ensure an environment free from accident hazards regarding the storage of sharps, specifically blood sugar testing lancets, in one of four medication carts reviewed. On 5/7/24 at 8:15 AM, an observation revealed that the first-floor medication cart had a small, white plastic container with a handle, containing approximately 40 individual blood sugar testing lancets, stored on top without a covering or lid. There was no nurse in view of the cart or the surrounding area. When questioned, Nurse 'W' and Nurse 'C' were unable to explain why the lancets were stored in the container on top of the cart. The Director of Nursing (DON) confirmed that the lancets should not have been stored on top of the cart and directed Nurse 'W' to place the container inside the medication cart. The facility's Medication Storage Checklist Tool dated 6/2023 did not address the process for storing lancets before use.
Failure to Document and Assess Bed Rail Use
Penalty
Summary
The facility failed to have a system in place prior to installing assist bars/rails to ensure appropriate consent, assessment, and physician orders were completed with ongoing monitoring and assessment for eight residents. This resulted in the potential for inappropriate use and/or injury from the device. The deficiency was identified through observation, interview, and record review, revealing that the facility did not follow its own guidelines for bed rail device evaluation and documentation. For instance, Resident 32, who had moderate cognitive impairment, had assist rails/bars on their bed without any initial or follow-up assessments, clinical rationale, consent, or physician orders documented in their Electronic Medical Record (EMR). Similarly, Resident 42, who had intact cognition and required substantial staff assistance for mobility, also had assist rails without the necessary documentation and assessments. This pattern was consistent across other residents, including those with intact cognition and those with moderate cognitive impairment, indicating a systemic issue. Interviews with the Director of Rehab, physical therapist, and Director of Nursing revealed that there was a lack of clear responsibility and documentation regarding the assessment and need for assist bars/rails. The facility's own guidelines stipulated the need for regular bed maintenance, individual bed rail evaluations, informed consent, and physician orders, none of which were consistently followed. This lack of adherence to established protocols posed a potential risk to all 76 residents of the facility.
Insufficient Nursing Staff Leads to Delayed Medication Administration
Penalty
Summary
The facility failed to ensure sufficient nursing staff was provided for the residents on the first floor, resulting in delayed medication administration and increased potential for unmet care needs. Multiple residents, including R72, reported concerns about not receiving timely care and assistance. The resident council minutes highlighted ongoing issues with call lights not being answered promptly and insufficient nursing staff, particularly when agency staff were present. Specific complaints included cold food, infrequent showers, and agency staff being inattentive and unprofessional. R72 specifically reported not receiving their scheduled medications on time, which was confirmed by a review of their Medication Administration Records (MARs) showing blank entries for the 9:00 AM medications. Nurse 'C', an agency nurse, admitted to being overwhelmed with the number of residents and tasks, leading to delays in medication administration. The Director of Nursing (DON) acknowledged the concerns but indicated that no additional nursing staff had been added despite discussions. The facility's policies on staffing and medication administration were not adhered to, as medications were not administered within the prescribed time frame, and there was no documentation of physician notification for late administration. Interviews with other nursing staff confirmed that only one nurse was typically assigned to the first floor, making it challenging to administer medications on time. The DON later confirmed that 11 out of 30 residents on the first floor required two-person assistance, further highlighting the inadequacy of the staffing levels.
Infection Control and Linen Storage Deficiencies
Penalty
Summary
The facility failed to ensure appropriate infection control practices with regards to Enhanced Barrier Precautions (EBP) and linen storage for eight residents. Observations revealed that residents with conditions requiring EBP, such as surgical wounds, colostomies, tube feedings, and indwelling catheters, did not have signs posted indicating the type of precautions and PPE required. Additionally, no PPE was readily available for staff use, and no staff were observed wearing PPE during direct care activities for these residents. The Director of Nursing (DON) and Unit Manager acknowledged the oversight but had not implemented the necessary precautions. For instance, one resident with a large dressing on their right lower leg had no EBP signs or PPE available, despite having a surgical wound. Another resident with a colostomy bag also lacked EBP signs and PPE. Similar deficiencies were noted for residents with tube feeding pumps, catheters, and other indwelling devices. The DON confirmed awareness of the EBP changes but admitted that no residents had been properly identified or labeled for EBP. Additionally, the facility failed to maintain proper linen storage practices. Observations of linen carts revealed the presence of personal care items, briefs, wipes, and even a used Styrofoam cup stored directly with clean linens. The DON confirmed that these items should not be stored with linens and began removing them. However, the facility's policy did not address the storage of non-linen items with linens, indicating a gap in their infection control procedures.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by the actions of an LPN towards a resident (R73). The resident, who was cognitively intact and had a history of traumatic subdural hemorrhage, a displaced trimalleolar fracture, and confirmed adult physical abuse, reported that the LPN accused them of drug-seeking behavior in front of other residents and staff. This accusation affected how other staff treated the resident. The resident's care plan included interventions for pain management, but the LPN's progress notes contained subjective and inappropriate comments about the resident's behavior and attitude, which were not aligned with the facility's policy on resident rights to be treated with respect and dignity. The Director of Nursing (DON) acknowledged that subjective information should not be included in progress notes and admitted that the LPN's notes were inappropriate. Despite the resident's complaints and the subjective nature of the LPN's documentation, the DON was unaware of any personality conflict between the resident and the LPN. The LPN admitted to having a weakness in subjective charting but denied any personal issues with the resident. The facility's policy on resident rights emphasized the importance of treating residents with respect, kindness, and dignity, which was not upheld in this case.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident (R12) was assessed for safe self-administration of medication. R12, a long-term resident with diagnoses including pneumonia, lung cancer, and depression, was observed with an albuterol inhaler on their bedside table, which they reported using as needed. Despite having a BIMS score of 15/15, indicating intact cognition, there was no documentation in R12's Electronic Medical Record (EMR) or care plan regarding their ability to self-administer medication. Interviews with the unit manager and LPN confirmed that R12 was self-administering the inhaler without an assessment or care plan in place. The Director of Nursing (DON) acknowledged the lack of an assessment and care plan for R12's self-administration of medication. The facility's policy on self-administration of medication was requested but not provided before the survey exit. This oversight indicates a failure in the facility's process to ensure residents are safely administering their medications as per physician orders.
Resident's Right to Refuse Room Change Not Upheld
Penalty
Summary
The facility failed to ensure a resident with a confirmed history of physical abuse was not threatened to change rooms for staff convenience. The resident, who was cognitively intact and had a history of traumatic subdural hemorrhage and a trimalleolar fracture, expressed issues with a particular LPN and requested not to have this nurse assigned to them. The resident was told by the Administrator that they would have to change rooms to avoid the LPN, despite the resident's attachment to their current room as a safe place. The Administrator did not consider utilizing other nurses in the facility to accommodate the resident's preference. The resident's comprehensive care plan included a focus on providing a safe environment due to their history of physical abuse. However, the facility's actions contradicted this care plan by suggesting a room change instead of addressing the resident's concerns about the LPN. The facility's policy on resident rights, which supports residents in exercising their rights, was not upheld in this instance. The Administrator's response indicated a lack of consideration for the resident's preferences and safety needs, leading to the deficiency noted in the report.
Failure to Administer Medications on Time and Notify Physician
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice for one resident reviewed for medication administration. During a confidential resident council meeting, several residents voiced concerns about frequently receiving their medications late. One resident, who was their own responsible party, reported not receiving their scheduled 9:00 AM medications and questioned if it was their responsibility to ask for them. A review of the resident's Medication Administration Records (MARs) revealed that none of the 9:00 AM medications had been documented as administered, and there was no documentation that the physician had been notified or approved the late administration. An interview with Nurse 'C', who was from a staffing agency, revealed that they were unsure how many residents they had left to administer medications to and expressed concern about the workload. The Director of Nursing (DON) acknowledged the concerns raised by residents and reported that other staff should be available to help when needed. Despite being informed of the issues, the DON confirmed that the medications were later documented as administered without proper notification to the physician, and the documentation falsely reflected that the medications were given at the scheduled time. Further review of the clinical record and interviews with the DON revealed that the facility's process for late medication administration was not followed. The facility's policy required medications to be administered within one hour of the prescribed time, and if not, the physician should be notified. However, there was no documentation of physician notification for the late administrations, and the facility's policy did not address this requirement. The DON also reported that the staffing levels and assistance required for residents were not adequately managed, contributing to the delay in medication administration.
Failure to Implement Pressure Ulcer Prevention and Conduct Skin Assessments
Penalty
Summary
The facility failed to consistently implement interventions to prevent the development of a new pressure ulcer and/or worsening of an existing pressure ulcer for one resident and failed to ensure skin assessments were completed for another resident. Resident R42, who had multiple serious health conditions and was dependent on staff for mobility, was observed multiple times without the necessary pressure-relieving interventions in place. Despite having a low air loss mattress and heel offloading boots ordered, these were not utilized, and R42 was left lying on a regular mattress with heels unsupported. The staff failed to implement the ordered interventions, and there was a lack of communication and follow-through among the staff and maintenance department regarding the necessary equipment and care for R42. Resident R9, who had moderate cognitive impairment and was always incontinent of bowel and bladder, was observed sitting in a wheelchair and later in the dining room without being offered or assisted with toileting or incontinence care for an extended period. The CNA assigned to R9 was unaware of the resident's incontinence needs and did not check or assist the resident as required. Additionally, R9's clinical record revealed a lack of documented skin assessments from March to May, despite having an order for weekly skin checks. The DON acknowledged the lapse in monitoring and the concern it raised. The facility's failure to implement and follow through with the necessary interventions and assessments for pressure ulcer prevention and management for both residents highlights significant deficiencies in care and communication among the staff. The lack of adherence to the care plans and orders resulted in inadequate care for residents at risk of skin breakdown and pressure ulcers.
Failure to Document Intermittent Catheterization
Penalty
Summary
The facility failed to ensure complete and accurate documentation of intermittent catheterization for a resident with quadriplegia and neuromuscular dysfunction of the bladder. The resident reported experiencing significant discomfort due to difficulty urinating and requested catheterization. The midnight nurse deferred the procedure to the day nurse due to an impending shift change. When the day nurse performed the catheterization, a substantial amount of urine (1200 ml) was obtained, but this amount was not documented in the resident's records. Additionally, the midnight nurse had previously obtained 900 ml of urine at 9:00 PM the night before, but this was also not documented properly. Review of the resident's Treatment Administration Record revealed that the catheterization procedure was not documented for two scheduled times on the previous day. The Director of Nursing confirmed that the amount of urine obtained from catheterization should be documented to inform the physician about the resident's urine retention levels. The lack of documentation was acknowledged, but no further documentation was provided before the end of the survey.
Failure to Ensure Adequate Indication and Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure a resident prescribed psychotropic medication had adequate indication for use, appropriate consent, and clinical rationale to support continued use in the absence of mood or behavior symptoms. The resident, who was admitted with multiple diagnoses including vascular dementia and anxiety, was observed to be moderately cognitively impaired but had no documented behavior concerns or hallucinations. Despite this, the resident was prescribed Seroquel for depression without any attempt at gradual dose reduction or physician documentation that a reduction was clinically contraindicated. Additionally, the care plan lacked specific details on the clinical rationale for the medication or target behaviors for staff to monitor. The social service assessment for the resident was incomplete and flagged as overdue, and there was no documentation indicating the resident had been deemed incompetent. The Social Service Director confirmed that the resident's spouse had signed a generic consent form without identifying clinical rationale or targeted behaviors, despite the resident being listed as their own responsible party. The Medical Director and a contracted psychologist had conflicting opinions on the resident's competency, but the Medical Director's assessment did not provide specific clinical rationale for the use of the antipsychotic medication. Further review of the clinical record revealed no additional documentation or completed assessments to support the use of the antipsychotic medication. The facility's policy on psychotropic medication management was not followed, as there was no informed consent from the resident, no appropriate monitoring for mood or behavior, and no individualized care plan reflecting pharmacological and non-pharmacological interventions. The lack of supporting documentation resulted in the unnecessary use of psychotropic medication and the inability to monitor its effectiveness.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to provide the required 80 square feet per resident in multiple resident rooms for 26 out of 42 rooms. This deficiency was identified through observation, interview, and record review. Specific rooms, including rooms 101 through 113 and 201 through 213, were found to have less than the required space, with room sizes ranging from 145 to 156 square feet for two residents. Despite individual interviews with residents revealing no complaints regarding the room size, the facility did not meet the regulatory requirements for room space per resident.
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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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