The Villa At Parkridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Ypsilanti, Michigan.
- Location
- 28 S Prospect Street, Ypsilanti, Michigan 48198
- CMS Provider Number
- 235503
- Inspections on file
- 33
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Villa At Parkridge during CMS and state inspections, most recent first.
A resident experienced a fall resulting in a hip fracture that was not immediately assessed or reported to the physician or responsible party. An LPN and CNA assisted the resident back to bed without documenting the fall or conducting a full assessment, including range of motion or neuro checks. The incident was only discovered after the resident reported pain to therapy and the guardian was informed by the roommate, leading to delayed hospital transfer and diagnosis.
The facility did not adequately address repeated concerns from the Resident Council about food palatability, call light response times, and provision of evening snacks. Residents reported long waits for call light responses, particularly during afternoon and night shifts, and noted that staff sometimes consumed snacks meant for residents. Additionally, grievances and concerns raised by the Resident Council were not satisfactorily resolved.
The facility failed to accurately complete MDS assessments for several residents, leading to discrepancies in medical records. A resident did not receive a pneumococcal vaccination despite consent, and another had incorrect documentation regarding a Gradual Dose Reduction. Weight loss data was inaccurately recorded for a resident, and the use of bed bolsters as potential restraints was not properly assessed for two residents. The facility's staff provided conflicting information about restraint use, indicating a lack of proper assessment and documentation.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies in care. A resident with bullous pemphigoid had an unplugged pressure mattress, another on dialysis lacked proper monitoring and care plan updates, a resident with psychiatric conditions had missing behavioral interventions, and a resident with a history of falls had an inaccessible call light. These issues highlight a lack of proper care plan implementation and monitoring.
The facility failed to provide adequate staffing, resulting in delayed response times to call lights, particularly during afternoon and night shifts. Residents reported waiting 45 to 60 minutes for assistance, with some experiencing incontinence due to the delays. Staff were observed turning off call lights without providing care, and residents' concerns about staffing were not addressed.
The facility failed to provide palatable and safe food, affecting 125 residents. Several residents expressed dissatisfaction with the quality and temperature of the food, leading some to store personal food items unsafely. Food trays were transported in non-insulated carts, contributing to improper food temperatures. The facility's meal distribution policy did not ensure proper temperature maintenance, as evidenced by surveyor observations and resident complaints.
A resident reported missing clothing items that were not returned from the laundry, despite being labeled. The facility staff failed to follow the grievance process, as no grievance form was completed, and the Nursing Home Administrator confirmed no grievances were documented. The resident was cognitively intact and had diagnoses including adjustment disorder and Alzheimer's Disease.
The facility failed to assess bed bolsters as potential restraints for two residents, leading to a deficiency. One resident with schizoaffective disorder and dementia had bolsters that restricted their ability to get out of bed, and another resident with a history of falls had a positioning wedge and bolster that prevented them from getting out of bed. The medical records lacked restraint assessments, and staff confirmed the use of bolsters for fall prevention without proper evaluation.
A facility failed to timely complete a Significant Change MDS assessment for a resident with dementia who had recently ended hospice services. The assessment, required within 14 days of a significant change, was completed late, as confirmed by the MDS Coordinator.
The facility failed to provide necessary care and assistance with ADLs for two residents, resulting in unmet personal care preferences and lack of engagement in activities. One resident, with multiple medical conditions, was not assisted in participating in activities like bingo, while another resident, with severe cognitive impairment, did not receive showers as preferred due to a broken shower bench. The staff's inaction and lack of proper documentation contributed to the deficiency.
A resident in a long-term care facility, who was cognitively intact and dependent on all care, was not provided with meaningful and individualized activities, leading to potential feelings of depression and boredom. Despite expressing a desire to participate in activities like Bingo, the resident was not assisted in getting out of bed in time to attend. Staff interviews revealed a lack of coordination and communication, and records showed no documented participation in activities over the past 30 days.
The facility failed to manage the nutritional care and weight of two residents effectively. One resident, who was cognitively intact and had a gastrostomy, experienced significant weight gain without adjustments to their tube feeding regimen, despite their preference for weight loss. Another resident, with severe cognitive impairment, suffered significant weight loss, and the facility did not update their care plan with new interventions. The facility did not adequately address the nutritional needs and preferences of these residents.
A facility failed to ensure proper dialysis care for a resident with end-stage renal disease. The resident reported that their dialysis access site was not routinely monitored, and there was no active physician's order for their fluid restriction. The Kardex did not reflect the resident's dialysis status or care considerations. Interviews with staff revealed inconsistencies in understanding the resident's care needs, and the Director of Nursing acknowledged that necessary orders were not reimplemented after a hospital visit.
A resident with a cerebral infarction was not provided with necessary personal items and expressed dissatisfaction with having a legal guardian and being unable to leave the facility. Despite being cognitively intact, the resident's requests for basic supplies and communication with the guardian were not adequately addressed by social services or nursing staff. The resident's condition worsened to suicidal ideation, highlighting the facility's failure to provide timely and appropriate social services.
A resident did not receive their prescribed morning dose of Lithium Carbonate due to a medication administration error. An RN pre-filled a medication cup and stored it in the medication cart, but failed to include the Lithium capsule. The Director of Nursing confirmed that medications should be administered directly from the bubble pack at the time they are due.
A resident with celiac disease was not provided meals that adhered to her gluten-free diet, as the facility frequently substituted her meals with hot dogs and hamburgers. Despite having a diet order for a gluten-free diet with extra protein, the resident reported a lack of dietician visits and a downward trend in her weight. Staff interviews confirmed the resident's complaints, indicating a failure to meet her dietary needs.
A facility failed to ensure proper collaboration and communication with a hospice provider for a resident receiving hospice services. Despite a scheduled hospice visit calendar, documentation was lacking in both the Hospice Binder and the electronic medical record. Interviews revealed that hospice visit notes were expected to be available but were not, and a request for the hospice communication log was not fulfilled before the survey exit.
A resident with severely impaired cognitive skills did not receive a pneumococcal immunization despite consent from their DPOA. The ADON/IP confirmed the consent but was unsure why the immunization was not administered.
The facility failed to update care plans for two residents, one experiencing significant weight loss and another with unadjusted tube feeding despite oral intake. The care plans did not reflect current needs and preferences, leading to deficiencies in care.
A resident suffered second-degree burns after a CNA failed to check the temperature of reheated noodles, which were then spilled. The facility did not follow proper procedures for reheating food or providing immediate burn care. Staff were inadequately trained on these protocols, contributing to the incident.
A resident suffered burns from hot noodles due to inadequate temperature checks and delayed physician notification. The facility failed to provide immediate and appropriate burn treatment, and staff were not adequately trained in reheating food or responding to burn injuries.
A resident suffered second-degree burns after spilling hot noodles on himself due to inadequate food temperature checks and lack of immediate burn care. The facility failed to report the incident promptly and lacked proper training and policies for reheating food and treating burns, contributing to the resident's injuries.
A resident with multiple health issues and a BIMS score indicating cognitive intactness was not informed of the resolutions to grievances they submitted regarding facility concerns. Despite documentation of actions taken, the facility's computerized system did not track whether the resident was notified, and the Nursing Home Administrator could not confirm that the resident was informed or satisfied with the outcomes.
Failure to Notify Physician and Responsible Party After Resident Fall With Major Injury
Penalty
Summary
The facility failed to immediately assess and notify the physician and responsible party following a fall with major injury for one resident. The resident was found sitting next to his bed and was unable to articulate what happened. The LPN and CNA assisted the resident back to bed, and the LPN documented that there were no injuries or pain and that a body assessment was conducted. However, there was no documentation of a fall on the date of the incident, and no evidence that the physician or responsible party was notified at that time. Additionally, there was no documentation of range of motion assessment or neuro checks following the incident. The resident later complained of right hip pain to occupational therapy, who then notified nursing. The resident's guardian learned of the fall from the resident's roommate and requested immediate hospital transfer, where a right hip fracture requiring surgical repair was discovered. Interviews with staff revealed that the LPN who found the resident did not notify the physician or responsible party and did not perform a range of motion assessment. The DON confirmed that the facility's expectation was for the physician and responsible party to be notified after any incident once the resident was assessed and safe.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address and respond to repeated concerns raised by the Resident Council regarding food palatability, call light response times, provision of evening snacks, and satisfactory resolutions to grievances. Review of the Resident Council Minutes from February to December 2024 indicated ongoing issues with the taste of food and delayed call light responses, particularly during the afternoon and night shifts. During a confidential resident group meeting, the majority of residents reported that their concerns about food taste and staffing had been discussed without any corrective actions being taken. Residents experienced long waits for call light responses, ranging from 45 to 60 minutes, and one resident noted that staff were often heard chatting at the nurse's station while call lights were on. Additionally, some residents reported that snacks were not offered, and staff would sometimes consume the snacks meant for residents. Several residents also expressed dissatisfaction with the resolution of grievances and concerns raised by the Resident Council.
Inaccurate MDS Assessments and Restraint Mismanagement
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for several residents, leading to discrepancies in their medical records. For Resident #48, the MDS indicated that the pneumococcal vaccination was offered and declined, despite the Durable Power of Attorney for Healthcare having consented to the vaccination. The resident did not receive the vaccination, and the MDS Coordinator admitted to not reviewing consents when completing assessments. Resident #103's MDS assessments were inaccurately coded regarding a Gradual Dose Reduction (GDR) for medications. The MDS indicated that a GDR was attempted and documented as clinically contraindicated, which was incorrect as no GDR was attempted. The MDS Coordinator acknowledged the coding errors in the assessments. For Resident #374, the MDS inaccurately reflected weight loss data, failing to indicate a significant weight loss that occurred. The Registered Dietician and MDS Nurse both confirmed the inaccuracy. Additionally, Residents #63 and #25 had issues with the use of bed bolsters, which were not properly assessed as potential restraints. The facility's Director of Nursing and MDS Coordinator provided conflicting information about the use of bolsters, indicating a lack of proper assessment and documentation regarding restraint use.
Deficiencies in Care Plan Implementation for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. Resident #48, who was admitted with bullous pemphigoid and had severely impaired cognitive skills, was observed multiple times with an alternating pressure mattress that was not functioning. Despite a physician's order to monitor the mattress, it was found unplugged, and staff had to troubleshoot the issue. This indicates a lack of proper monitoring and implementation of the care plan for skin integrity. Resident #75, who was cognitively intact and dependent on renal dialysis, reported that their dialysis access site was not routinely monitored by nursing staff. The resident's care plan and Kardex did not reflect their dialysis status or the location of the access site, which is crucial for their care. Additionally, the Nutrition Care Plan was not initiated until six months after admission, showing a significant delay in addressing the resident's nutritional needs. Resident #109, with a history of psychiatric conditions, had a care plan that did not include behavioral interventions known to be effective, such as changing conversation topics to reduce agitation. This omission was acknowledged by the Director of Nursing. Similarly, Resident #25, who had a history of falls and anoxic brain damage, was observed with a call light out of reach, contrary to the care plan intervention to ensure it was accessible. This oversight could prevent the resident from communicating needs effectively, highlighting a failure to implement the care plan for fall prevention.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to maintain sufficient staffing levels to meet the needs of residents, particularly during the afternoon and night shifts. This deficiency was highlighted by ongoing concerns documented in the Resident Council Minutes, which reported long call light response times ranging from 45 to 60 minutes. During a confidential resident group meeting, the majority of residents expressed that their concerns about staffing had not been addressed, with reports of staff being inattentive and spending extended periods at the nurse's station without responding to call lights. Specific incidents involved three residents who experienced significant delays in receiving care. One resident reported that staff would turn off the call light without providing the requested service, leading to prolonged waits for assistance. Another resident, who required two-person assistance, reported that it took hours for staff to respond to their call light at night. A third resident experienced delays of 30 to 45 minutes, particularly around meal times and shift changes, resulting in instances of incontinence due to the wait for assistance.
Facility Fails to Provide Palatable and Safe Food
Penalty
Summary
The facility failed to provide palatable and safe food products, affecting 125 residents, which increased the likelihood of decreased resident food acceptance and nutritional decline. Multiple residents expressed dissatisfaction with the quality and temperature of the food. Resident #94 mentioned that the food could be better and expressed a preference for more than just hamburgers and hot dogs. Resident #105 reported a desire for specific nutritious vegetables and noted that the facility's green beans were often inedible, the rice was tough, and the beans were sour. Resident #103 complained about the poor taste and temperature of the food, particularly breakfast items, and resorted to storing personal food items in their room due to dissatisfaction with the facility's offerings. The surveyor observed that Resident #103 stored personal food items on a windowsill, using the open window for limited refrigeration, which is not a safe practice. The facility's policy on safe storage and handling of outside food was not adhered to, as the resident's food was not properly labeled or stored in a designated refrigerator. Additionally, Resident #65 criticized the facility's grilled cheese sandwiches and reported that the food was often cold and of poor quality, describing the meat as rubbery. During the survey, food trays were observed being transported in non-insulated carts, which likely contributed to the improper food temperatures recorded. The pork loin and green beans served to Resident #65 were below the required temperature, while the pineapple tidbits, lemonade, and yogurt were above the safe temperature for cold foods. The facility's meal distribution policy was not effectively ensuring proper temperature maintenance, as evidenced by the surveyor's palatability tests, which found some food items to be bland, cold, or of poor quality.
Failure to Resolve Resident Grievance Regarding Missing Clothing
Penalty
Summary
The facility failed to promptly resolve grievances for a resident, identified as R88, who was admitted with diagnoses including adjustment disorder with depressed mood and Alzheimer's Disease. R88, who was cognitively intact as per the Brief Interview for Mental Status, reported missing several clothing items, including sweatshirts, pants, t-shirts, and a green plaid jacket. Despite the items being labeled with R88's name, they were not returned from the laundry. R88 expressed uncertainty about whether a grievance form was filled out on their behalf. Interviews with facility staff revealed that the grievance process was not properly followed. Certified Nursing Assistant X acknowledged being informed by R88 about the missing items and verbally communicated this to the laundry staff but did not complete a grievance form. The Environmental Services Director indicated that all missing clothing items should be processed through the grievance system but was unsure if a follow-up was conducted with R88. The Nursing Home Administrator confirmed that no grievances related to the missing items were documented for R88, highlighting a failure in the facility's grievance handling process.
Failure to Assess Bed Bolsters as Potential Restraints
Penalty
Summary
The facility failed to assess the use of bed bolsters as potential restraints for two residents, leading to a deficiency in ensuring residents are free from physical restraints unless needed for medical treatment. Resident #63, who has schizoaffective disorder and unspecified dementia, was observed with bed bolsters that restricted their ability to get out of bed independently. The medical record did not reflect an assessment of the bolsters as restraints, and staff interviews indicated that the bolsters were used to prevent the resident from rolling out of bed, despite the resident's cognitive deficits preventing consistent removal of the bolsters. Similarly, Resident #25, with a history of falling, anoxic brain damage, and dementia, was observed with a positioning wedge and bolster that prevented them from getting out of bed. The resident's call light was out of reach, and the medical record lacked documentation of a restraint assessment. Staff confirmed that the bolsters and wedge were used to prevent falls, but the facility did not evaluate these as potential restraints. Interviews with the Director of Nursing and other staff revealed a lack of restraint assessments in the medical records for both residents. The facility's failure to assess the use of bed bolsters as potential restraints resulted in a deficiency, as the bolsters restricted the residents' freedom of movement without proper evaluation or documentation.
Delayed Completion of Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment in a timely manner for one resident out of 25 reviewed. The resident, who was admitted with a diagnosis of dementia, began hospice services on November 1, 2024, and ended these services on January 21, 2025. A Significant Change MDS assessment was initiated with an Assessment Reference Date of January 27, 2025, but was still in progress as of February 10, 2025, and was not completed until February 11, 2025. During an interview, the MDS Coordinator confirmed that the assessment was completed late, acknowledging that such assessments must be completed within 14 days of determining a significant change in the resident's condition, as per the Resident Assessment Instrument (RAI) Manual.
Deficiency in Providing Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for two residents, resulting in a deficiency. Resident #29, who has multiple medical conditions including acute and chronic respiratory failure, type 2 diabetes, and chronic obstructive pulmonary disease, was not assisted in participating in activities such as bingo, which she expressed a desire to attend. Despite being cognitively intact and dependent on all care, the staff did not facilitate her participation in activities, leaving her in bed during scheduled events. The care plan indicated that she should be reminded and assisted to attend activities, but there was no documentation of her participation in any activities over the last 30 days. Resident #49, who has severe cognitive impairment and multiple health issues such as cerebral infarction and end-stage renal disease, did not receive showers as preferred, instead receiving bed baths without hair washing. The resident expressed a desire for showers, but due to a broken shower bench, she was not provided with this option. The facility's records showed that she had not received a shower in the last 30 days, and oral care was documented at inappropriate times, such as during the middle of the night while she was sleeping. Additionally, there were discrepancies in the documentation of her ability to wheel herself in a manual wheelchair, which contradicted her assessed dependency on all care. The facility's failure to provide adequate care and assistance with ADLs for these residents resulted in a lack of engagement in activities and unmet personal care preferences. The staff's inaction and lack of proper documentation contributed to the residents not receiving the care needed to maintain their highest practicable well-being, leading to potential embarrassment and humiliation.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide meaningful and individualized activities for a resident, resulting in the potential for depression, boredom, and feelings of lack of self-worth. The resident, who was cognitively intact and dependent on all care, expressed a desire to participate in activities such as Bingo but was not assisted in getting out of bed in time to attend. Despite having a care plan that included reminders and assistance to attend activities, the resident was observed still in bed during a scheduled Bingo activity, and no staff member was seen assisting her to participate. Interviews with staff revealed a lack of communication and coordination in ensuring the resident's participation in activities. A CNA, unfamiliar with the resident's preferences, did not assist her in getting up for activities. The Activity Director acknowledged the resident's interest in participating but cited logistical challenges in getting her ready due to her need for a two-person mechanical lift. A review of the resident's records showed no documented participation in activities over the past 30 days, with staff only noting that the resident watched TV daily.
Failure in Nutritional Care and Weight Management
Penalty
Summary
The facility failed to honor dietary preferences and manage weight effectively for two residents, leading to deficiencies in nutritional care. Resident #79, who was cognitively intact and had a gastrostomy for nutritional support, experienced significant weight gain over several months. Despite the resident's preference for weight loss and maintenance, the facility did not adjust the tube feeding regimen or consult the physician about the weight gain. The Registered Dietitian noted the resident's overweight status and the presence of a stage four pressure ulcer, but the medical record lacked documentation of discussions with the resident or their responsible party about the risks and benefits of the current diet orders. Resident #374, who had severe cognitive impairment and was at risk for malnutrition, experienced a significant weight loss of 11.7% over one month. The resident's care plan was not updated with new interventions after this weight loss, and the facility failed to implement the recommendations from the nutritional progress notes. The resident's weight continued to decline, and the medical record did not reflect any new or additional preventive measures to address the ongoing weight loss. The Registered Dietitian at the time of the survey was unfamiliar with the resident's case and could not explain why the previous dietitian's recommendations were not fully implemented. The deficiencies highlight the facility's failure to provide adequate nutritional care and weight management for the residents, as evidenced by the lack of appropriate adjustments to dietary plans and insufficient communication with residents and their responsible parties. The facility did not take necessary actions to prevent weight gain in one resident and weight loss in another, resulting in unmet nutritional needs and preferences.
Failure to Monitor Dialysis Access Site and Update Care Plans
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for Resident #75, who required such services due to end-stage renal disease and dependence on renal dialysis. The resident reported that the nursing staff were not routinely monitoring their dialysis access site, which was located in their left arm. The resident also mentioned that they were on a fluid restriction, but there was no active physician's order for this in their medical record. The Kardex, which guides Certified Nurse Aides (CNAs) in providing care, did not reflect the resident's dialysis status, the location of their access site, or any related care considerations. Additionally, the resident's Medication Administration Record (MAR) for February 2025 did not include orders for monitoring or assessing the dialysis access site. Interviews with facility staff revealed inconsistencies and a lack of clarity regarding the resident's care needs. A CNA, who did not frequently work on the resident's floor, was unsure about the location of the dialysis access site and relied on the Care Plan and Kardex for guidance. The Registered Dietitian reported that the resident was not on a fluid restriction, contradicting the information provided by the Registered Nurse (RN) and the Director of Nursing (DON). The RN was unable to locate orders for monitoring the dialysis access site, and the DON acknowledged that the orders were discontinued after the resident's hospital visit and not reimplemented upon their return. The DON also stated that the expectation was for daily monitoring of the dialysis access site, which was not being documented as required.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services to a resident, identified as R375, who was admitted with a diagnosis of cerebral infarction. Despite being cognitively intact and able to communicate his needs and frustrations, R375 was not provided with necessary personal items such as clothing, shoes, and cigarettes, which were left at a previous facility. R375 expressed extreme dissatisfaction with his current situation, including having a legal guardian he did not want and being unable to leave the facility. The resident's requests for basic supplies and communication with his guardian were not adequately addressed by the facility's social services or nursing staff. R375's medical record indicated that he refused meals, showers, therapy, and medications, expressing a desire to be discharged from the facility. The social services notes revealed that the resident's guardian was aware of his behaviors and was in the process of finding another placement for him. However, the facility did not take steps to reassess the need for guardianship, despite R375's mental capacity to make his own decisions. The social workers were aware of the resident's dissatisfaction but did not take effective action to resolve his concerns or advocate for his needs. Interviews with social workers indicated a lack of initiative in addressing R375's situation, as they relied on the guardian to provide the requested items and did not pursue a competency evaluation to reassess the guardianship. The resident's condition worsened to the point of expressing suicidal ideation, yet the facility's response remained inadequate. The guardian eventually agreed to bring the resident's items and meet him at the hospital, but the facility's failure to provide timely and appropriate social services contributed to the resident's distress and unmet needs.
Medication Administration Error Due to Improper Storage
Penalty
Summary
The facility failed to ensure the safe storage and administration of medications for one resident, resulting in a medication error. During a medication administration observation, a Registered Nurse (RN) was seen removing a pre-filled medication cup from the top drawer of her medication cart, which she had filled earlier with the resident's 8:00 AM medications. The RN did not include the resident's prescribed Lithium Carbonate Oral Capsule 150mg in the medication cup, leading to the resident missing their morning dose. This incident was confirmed during an interview with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNA), where the DON stated that the expectation is for medications to be pulled from the bubble pack and administered directly at the time they are due.
Failure to Honor Gluten-Free Diet for Resident
Penalty
Summary
The facility failed to honor the food preferences and dietary needs of a resident diagnosed with celiac disease, which requires a gluten-free diet. The resident, who was cognitively intact, expressed frustration with the meals provided, stating that the kitchen frequently substituted her meals with hot dogs and hamburgers, sometimes including a bun, which is not gluten-free. Despite having a diet order for a gluten-free diet with extra protein due to pressure ulcers, the resident reported that the dietician had not visited her since her admission, and her weight was trending down. Interviews with facility staff confirmed the resident's complaints. A Certified Nursing Assistant (CNA) acknowledged that the resident was often sent hot dogs or hamburgers and was growing tired of them. The Registered Dietician (RD) stated that meat should not be substituted for residents with a gluten-free diet, indicating a failure to adhere to the dietary requirements. The deficiency was identified through observation, interviews, and record reviews, highlighting the facility's failure to provide meals that accommodate the resident's dietary needs and preferences.
Failure in Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure proper collaboration and communication with the hospice provider for a resident receiving hospice services. The resident, who had been diagnosed with neuromyelitis optica and cerebral infarction, was admitted and readmitted to the facility and was receiving hospice care. Despite having a hospice visit calendar that scheduled 14 visits from hospice staff, the Hospice Staff Collaboration Log only noted four visits, and there were no progress notes pertaining to hospice visits in the Hospice Binder. Additionally, the resident's electronic medical record lacked documentation of hospice service visits, and their care plan did not reflect the hospice disciplines involved in their care. Interviews with facility staff revealed that hospice visit notes should have been available in the Hospice Binder and scanned into the electronic medical record, but this was not done. The Social Services Director reported coordinating hospice services, and the Director of Nursing confirmed that hospice visit notes were expected to be accessible to staff. An email request for the hospice visit calendar and communication log was made to the Nursing Home Administrator, but the hospice communication log was not provided before the survey exit.
Failure to Administer Pneumococcal Immunization
Penalty
Summary
The facility failed to administer a pneumococcal immunization to a resident, identified as R48, despite having received consent from the resident's Durable Power of Attorney (DPOA) for Healthcare. R48 was admitted to the facility with severely impaired cognitive skills for daily decision-making, as noted in the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/11/25. The medical record indicated that the pneumococcal immunization was not up to date, and although it was offered, it was initially declined. However, the Vaccine Consent and Administration Form showed that the DPOA consented to the immunization on 4/17/24. Despite this consent, the immunization was not administered. During an interview, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) acknowledged the consent but was unsure why the immunization had not been given.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in their care. Resident #374 experienced a significant weight loss of 11.7% in one month, which was not reflected in their care plan. Despite being at risk for malnutrition due to their medical condition, no updates or additional interventions were made to the care plan after the weight loss and hospitalization. The Registered Dietician, who was new to the facility, was unable to provide an explanation for the lack of updates to the care plan. Resident #79's care plan did not reflect their preference to consume breakfast by mouth, despite receiving the majority of their nutrition through tube feeding. The resident reported gaining 20 pounds and consuming meals by mouth, but their tube feeding regimen had not been adjusted accordingly. The Director of Nursing acknowledged that the resident's meals should have been care planned, indicating a failure to update the care plan to reflect the resident's current nutritional preferences and needs.
Resident Burned Due to Unsafe Food Temperature
Penalty
Summary
The facility failed to ensure that hot food was served at a safe temperature, resulting in a resident suffering second-degree burns. The resident, a cognitively intact male with multiple health conditions including diabetes and chronic kidney disease, requested a CNA to heat a cup of noodles. The CNA heated the noodles in the microwave for 3-4 minutes and returned them to the resident without checking the temperature. The resident accidentally spilled the hot noodles on himself, causing burns to his abdomen, groin, and right thigh. The incident was not immediately reported to the necessary parties, including the physician, DON, and NHA. The initial response to the burn was inadequate, as the RN who assessed the resident did not apply appropriate first aid measures such as cooling the burn with water. Instead, petroleum jelly was applied, which is not recommended for acute burns. The incident was not documented in a timely manner, and the facility's policy on reheating food was not followed. Interviews with staff revealed a lack of training and awareness regarding the facility's policies on reheating food and immediate burn treatment. Several staff members, including CNAs and LPNs, were unaware of the correct procedures for checking food temperatures and providing first aid for burns. The facility's microwaves were not equipped with thermometers, and staff were not trained to use them prior to the incident. This lack of training and policy enforcement contributed to the resident's injury and the facility's failure to prevent the accident.
Delayed Physician Notification and Inadequate Burn Treatment
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, resulting in a delay in treatment of a burn and increased risk for pain and infection. The resident, a cognitively intact male with multiple medical conditions including diabetes and heart failure, accidentally spilled hot noodles on himself while eating in bed. The incident occurred when a CNA heated the noodles in a microwave for 3-4 minutes and returned them to the resident without checking the temperature. The resident suffered burns to his abdomen, groin, and right thigh. The incident was not reported to the physician, Director of Nursing, Nursing Home Administrator, or family member until over 15 hours later. Initial first aid was inadequate, as the RN who assessed the resident did not apply cool compresses or notify the physician immediately. The resident reported significant pain at the time of the incident, but this was not documented or addressed promptly. The facility lacked a clear policy for immediate burn treatment, and staff were not adequately trained in reheating food or responding to burn injuries. Interviews with staff revealed a lack of awareness and training regarding the facility's reheating policy and immediate response to burns. The microwaves were removed from resident floors after the incident, and staff were instructed to use a microwave in the staff breakroom. However, there was confusion about the appropriate temperature for serving food and the facility's policy on reheating. The facility's failure to provide timely and appropriate care for the resident's burns highlights deficiencies in staff training and communication protocols.
Failure to Provide Adequate Burn Care and Food Safety
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practical physical well-being of a resident, resulting in second-degree burns. The resident, a cognitively intact male with multiple health conditions including diabetes and hemiplegia, requested a CNA to heat a cup of noodles. The CNA heated the noodles in the microwave for 3-4 minutes and returned them to the resident, who was in bed. The resident accidentally spilled the hot noodles on himself, causing burns to his abdomen, groin, and right thigh. The incident was not immediately reported to the necessary parties, including the physician, Director of Nursing, and Nursing Home Administrator, until over 15 hours later. Initial first aid provided by the RN was inadequate, as it did not include cooling the burn areas with normal saline or cool cloths. The facility lacked a clear policy or training for immediate burn treatment, and staff were not educated on the proper procedures for heating and reheating food prior to the incident. Interviews with staff revealed a lack of awareness and training regarding the facility's reheating policy and immediate burn care. The CNA involved did not check the food temperature before serving it to the resident, and there was no thermometer available for staff use at the time. The facility's failure to follow its reheating policy and provide immediate and appropriate burn care contributed to the severity of the resident's injuries.
Failure to Notify Resident of Grievance Resolutions
Penalty
Summary
The facility failed to notify a resident of the investigation and resolution of grievances they had submitted. The resident, who was admitted with multiple diagnoses including cirrhosis of the liver, anxiety, and depression, was cognitively intact as indicated by a BIMS score of 15 out of 15. The resident expressed frustration during an interview, stating that they had submitted two concern forms regarding issues such as bathroom cleanliness, dietary requests, and roommate disturbances, but had not been informed of any resolutions. The grievance forms, dated in early July, documented that various managers had been notified and discussions had taken place to address the concerns. However, the forms did not indicate that the resident had been informed of these resolutions. The Nursing Home Administrator acknowledged that the computerized grievance system did not track whether residents were notified of the outcomes, and could not provide evidence that the resident had been informed or satisfied with the resolutions. The facility's grievance policy required a response to the resident, which was not demonstrated in this case.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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