The Villa At The Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Highland Park, Michigan.
- Location
- 111 Ford Avenue, Highland Park, Michigan 48203
- CMS Provider Number
- 235463
- Inspections on file
- 31
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Villa At The Park during CMS and state inspections, most recent first.
A CNA struck a resident with impaired cognition during an altercation, resulting in a visible bruise. The CNA admitted to not following abuse prevention training when responding to the resident's aggressive behavior. The DON confirmed awareness of the incident, which was reported as staff-to-resident abuse.
The facility failed to control a cockroach infestation affecting all residents. Observations showed multiple rooms with cockroaches, and staff confirmed awareness of the issue. Structural issues and residents' personal food contributed to the problem. Despite increased pest control visits, the infestation persisted, indicating inadequate pest control measures.
The facility failed to prevent and document abuse incidents involving two residents, resulting in a broken leg and verbal abuse. One resident was pulled from their wheelchair by another resident with a history of aggression, while another resident reported being choked by an LPN. The facility did not complete required incident reports or investigations, highlighting deficiencies in abuse prevention and reporting procedures.
A resident with hypertension was improperly monitored, leading to the administration of blood pressure medications without appropriate assessment. Carvedilol and Spironolactone were given without documented blood pressure readings, and the physician was not notified of low blood pressure. The resident was transferred to the hospital and passed away shortly after. Interviews with staff revealed inconsistencies in following medication protocols.
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 104 residents. Surveyors observed soiled door gaskets and light lens covers in the food service area, violating the 2017 FDA Model Food Code. Additionally, the door gaskets of a cooler were worn and torn, further breaching code requirements. The facility's policy mandates that all equipment be clean, sanitary, and in proper working order.
The facility failed to maintain its outdoor waste and recycling receptacles, affecting 104 residents. Observations revealed missing lids, bent metal rods, and a heavily soiled cement pad. The waste grease container was rancid, and the facility did not adhere to its policy on garbage disposal, which requires maintaining a clean area and providing appropriate lids.
The facility failed to maintain a clean and safe environment, with surveyors observing numerous issues such as heavily soiled air conditioning units, disorganized storage rooms, and pest infestations. Maintenance issues like non-functional ventilation systems and leaking faucets were also noted. The facility's maintenance system, TELS, lacked entries addressing these concerns, indicating poor communication and follow-up.
The facility failed to manage pest control effectively, impacting 104 residents. Observations included a broken door sweep allowing pest entry, cockroaches in various locations, and a housefly in the Administrator's Office. The pest control contract lacked specific treatments for targeted pests, and glue boards with dead cockroaches were found in resident rooms. A resident confirmed seeing cockroaches in their room.
The facility failed to date and store oxygen tubing properly for a resident with respiratory conditions, and staff members did not perform proper hand hygiene. Oxygen tubing was found undated and improperly stored, while hand sanitizer dispensers were empty, and staff did not wash hands after handling soiled items or before resident care. The ADON confirmed expectations for tubing storage and hand hygiene but provided incomplete education materials.
A resident with Parkinson's Disease and Dementia, standing six feet, four inches tall, was not provided with an appropriately sized bed, resulting in discomfort as their feet rested on the footboard. The resident expressed a preference for a bed that accommodated their height, but the facility failed to address this need. Observations showed the resident was unable to adjust themselves in the bed due to manual adjustments lacking a remote control. The facility's policy emphasized individualized care, which was not met.
The facility failed to investigate two incidents of alleged abuse involving residents and staff. In one case, a resident was injured after being pulled from their wheelchair by another resident, but no investigation was conducted. In another case, a resident alleged choking by a staff member, but the incident was not documented or reported. The facility did not follow its policy for investigating and reporting abuse, leading to significant deficiencies.
A facility failed to create a care plan for a resident with dementia who exhibited aggressive behaviors towards staff and other residents. Despite multiple documented incidents of aggression, the resident's care plan lacked interventions to address these behaviors, leading to safety concerns. The ADON confirmed the absence of a care plan for managing the resident's aggression.
A resident with cognitive impairment and a history of bacterial meningitis and aphasia did not receive consistent oral care, as observed over several days. Despite needing assistance, the resident's mouth remained dry and their teeth coated with residue. Interviews with staff confirmed the resident's dependency on assistance for oral hygiene, yet care was inconsistent, and the facility failed to provide a policy on ADL care.
A resident with a wound on their toe did not receive proper wound care as prescribed. Observations showed the bandage was not changed over several days, and staff interviews revealed a lack of adherence to treatment orders. The whirlpool tub needed for treatment was unusable, and the facility's wound care policy was not provided.
The facility failed to document or offer influenza and pneumonia vaccinations for two residents. One resident, with intact cognition, had no vaccine consents or records of being offered vaccines. Another resident's record showed a guardian-signed consent, but the resident refused the vaccines, and there was no documentation that the guardian was informed of this refusal.
The facility failed to offer and document the COVID-19 vaccine for a resident. During a review, it was found that the resident's medical record lacked vaccine consents and documentation of the vaccine being offered or administered. The resident had intact cognition, suggesting they could make informed decisions about vaccination. The ADON could not explain the oversight, indicating a lapse in the facility's vaccination protocol.
The facility failed to provide the required 80 square feet of living space per bed in multiple resident rooms, with 21 out of 36 rooms not meeting the standard. Despite this, residents interviewed stated they were not affected by the room sizes. The facility's policy emphasizes a safe and comfortable environment, which is contradicted by the observed room sizes.
Failure to Prevent Staff-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically struck a resident during an incident. The resident, who had diagnoses including Paranoid Schizophrenia, Encephalopathy, Anxiety Disorder, and Depressive Disorder, and was assessed as having impaired cognition, was observed with a purplish bruise under their left eye. The CNA reported that while working the midnight shift, the resident came out of their room swinging and punching, and in response, the CNA hit the resident in the face as a reflexive action. The CNA acknowledged having received training on abuse prevention and managing aggressive resident behaviors but admitted to not implementing this training during the incident. The Director of Nursing confirmed awareness of the incident and stated the expectation that residents are to be free from abuse and neglect by staff. The facility's policy prohibits all forms of abuse and mandates protection of residents from harm. The incident was reported to the state agency as an allegation of staff-to-resident abuse, and the deficiency was identified based on observation, interviews, and record review.
Cockroach Infestation Due to Inadequate Pest Control
Penalty
Summary
The facility failed to provide adequate pest control, resulting in a cockroach infestation that had the potential to affect all 102 residents. Observations revealed multiple rooms with adult cockroaches and nymphs in pest glue traps. Staff interviews confirmed awareness of the issue, with LPN B acknowledging the concern and Housekeeping Staff C noting the presence of dead cockroaches during cleaning. An anonymous resident reported seeing five bugs in their room within a week. The Nursing Home Administrator (NHA), Director of Nursing (DON), and Maintenance Director acknowledged the infestation, noting increased pest control visits in response. Further investigation revealed structural issues, such as a crack in the South door, which could facilitate pest entry. The Maintenance Director attributed the infestation to residents' personal food and hoarding behaviors. A review of pest control invoices indicated extensive cockroach activity in at least 18 resident rooms, primarily on the second floor. Despite ongoing pest control efforts, residents continued to report sightings of cockroaches, expressing concerns about their clothing. The facility's pest control contract outlined bi-monthly services, but the infestation persisted, indicating a failure in the pest control measures.
Failure to Prevent and Document Abuse Incidents
Penalty
Summary
The facility failed to prevent abuse involving two residents, R24 and R40, resulting in physical harm and verbal abuse. Resident R24 was reportedly pulled out of their wheelchair by another resident, R38, leading to a broken leg. Despite R38's history of aggressive behavior, including verbal and physical aggression towards staff and other residents, there was no care plan in place to address these behaviors. The incident was not properly documented, as the incident and accident report was incomplete and unsigned, and the facility's policy regarding incident documentation was not provided. Resident R40 reported being choked by LPN C, with CNA E corroborating the claim by noting redness on R40's neck and taking a photograph. Despite the serious nature of the allegation, there was no record of an incident report or investigation in R40's medical record. The facility's policy requires immediate reporting and investigation of abuse allegations, but this was not adhered to in R40's case. The ADON was unable to locate documentation of the incident or any investigation, indicating a failure in the facility's abuse prevention and reporting procedures. The facility's leadership, including the Nursing Home Administrator and Assistant Director of Nursing, failed to ensure that incidents of abuse were properly documented and investigated. The lack of a completed incident report for R24 and the absence of documentation for R40's allegations highlight significant deficiencies in the facility's handling of abuse cases. These failures are contrary to the facility's stated policy of preventing abuse and ensuring the safety and well-being of its residents.
Failure to Monitor and Administer Blood Pressure Medications Appropriately
Penalty
Summary
The facility failed to properly monitor and assess the blood pressure of a resident diagnosed with hypertension, leading to the inappropriate administration of blood pressure medications. The resident, identified as R104, was admitted with a diagnosis of Hidradenitis suppurativa and hypertension. The facility's records showed that Carvedilol, a medication to lower blood pressure, was administered without prior blood pressure documentation. Additionally, Spironolactone was given without a recorded blood pressure, and there was no evidence that the physician was contacted regarding the resident's low blood pressure. The resident's medical record lacked progress notes indicating physician notification, and the Medication Administration Record (MAR) did not include hold parameters for the blood pressure medications. Interviews with the Assistant Director of Nursing (ADON) and Licensed Practical Nurses (LPNs) revealed inconsistencies in following protocols for administering blood pressure medications, particularly when blood pressure readings were low. The resident was eventually transferred to the hospital due to a change in condition and subsequently passed away within 24 hours of the transfer. The facility did not provide a medication administration policy by the end of the survey.
Deficiency in Food Service Equipment Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 104 residents. During an initial tour of the food service area, surveyors observed that the door gaskets and upper door ledge of a 2-door reach-in cooler were soiled with accumulated and encrusted food residue. Additionally, all 12 overhead plastic light lens covers were found to be soiled with accumulated dust, dirt, and food residue. These observations indicate a failure to adhere to the 2017 FDA Model Food Code, which requires that equipment food-contact surfaces and utensils be clean to sight and touch, and that non-food-contact surfaces of equipment be kept free of an accumulation of dust, dirt, food residue, and other debris. Furthermore, the door gaskets of the 2-door reach-in cooler were observed to be worn and torn, with damaged gasket surfaces measuring approximately 12 inches and 8 inches long, respectively. This condition violates the 2017 FDA Model Food Code, which mandates that equipment be maintained in a state of repair and condition that meets specified requirements, including keeping equipment components such as doors and seals intact and tight. The facility's policy on kitchen equipment, dated 9-1-21, also requires that all food service equipment be clean, sanitary, and in proper working order, and that equipment be routinely cleaned and maintained in accordance with manufacturer's directions and training materials.
Improper Disposal and Maintenance of Waste Receptacles
Penalty
Summary
The facility failed to properly clean and maintain its outdoor waste and cardboard recycling receptacles, affecting 104 residents. During an environmental tour, it was observed that the cardboard waste receptacle was missing one of its two plastic lids, and the metal mounting rod was bent and convoluted. Additionally, the drain plug was missing from the cardboard waste receptacle port. The solid waste receptacle had offset plastic lids, and its metal mounting rod and rear metal brace bars were bent, unattached, and convoluted. These deficiencies were noted by the Regional Director of Dietary Services, who acknowledged the need for repairs. The cement pad surface where the waste receptacles were located was heavily soiled with accumulated and encrusted dirt and debris. A large plastic container with wheel castors was full of water, and two wooden containers were resting on the cement pad near the rear fence line. The waste grease container was observed with rancid and malodorous used grease product, and a large wooden skid was resting against it. The facility's policy on garbage and refuse disposal, dated 09/01/2021, requires that all garbage and refuse be collected and disposed of safely and efficiently, with the area surrounding the exterior dumpster maintained free of rubbish or debris, and appropriate lids provided for all containers. These observations indicate a failure to adhere to the facility's established policies and procedures.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, staff, and visitors, as evidenced by numerous observations of unclean and poorly maintained areas throughout the building. During an environmental tour, surveyors noted significant issues such as corroded and broken door sweeps, heavily soiled air conditioning units, and disorganized storage rooms. These conditions were observed in various locations, including dining rooms, utility rooms, and restrooms, where dust, dirt, and grime had accumulated, creating potential health hazards. In addition to the general lack of cleanliness, specific maintenance issues were identified, such as non-functional ventilation systems, leaking faucets, and missing or damaged fixtures. The surveyors also found evidence of pest infestations, with cockroaches observed in several areas, including resident rooms and the nurses' station. The facility's maintenance work order system, TELS, did not contain any entries addressing these concerns, indicating a lack of effective communication and follow-up on maintenance issues. The facility's failure to adhere to its own cleaning and maintenance policies further contributed to the deficiencies. The policies outlined procedures for daily cleaning and preventative maintenance, yet the observations made during the survey indicated that these procedures were not being followed. The accumulation of dust, dirt, and debris, along with the presence of pests, suggests a systemic issue in maintaining a safe and sanitary environment for residents and staff.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to effectively implement a pest control program, impacting 104 residents and increasing the likelihood of pest attraction and harborage. Observations revealed a corroded and broken door sweep at the rear building entrance, creating a significant air gap that could allow pests to enter. Cockroaches were observed in various locations, including the 1st floor Back Dining Room entrance, the 2nd Floor Nurses Station, and resident rooms. A housefly was also noted in the Administrator's Office during a team meeting. The facility's pest control contract outlined treatment categories and frequencies, but a review of the Pest Control Technician Treatment Invoices for the past 12 months showed no specific treatments for targeted pests, only general pest treatments. During an environmental tour, glue boards with numerous dead cockroaches were found in resident rooms, indicating ongoing pest issues. An interview with a resident confirmed sightings of cockroaches in their room, further highlighting the facility's failure to manage pest control effectively.
Deficiencies in Oxygen Tubing Storage and Hand Hygiene
Penalty
Summary
The facility failed to properly date and store oxygen tubing for a resident with Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure. The resident's oxygen tubing was observed on multiple occasions to be undated and improperly stored, with extra tubing lying on the floor and not bagged. The Assistant Director of Nursing (ADON) confirmed that the expectation was for oxygen tubing to be dated and stored in a bag when not in use. However, the facility's policy only addressed storage and safety related to oxygen cylinders or tanks, not tubing. Additionally, the facility failed to ensure proper hand hygiene among staff members. Observations revealed that four staff members did not perform hand hygiene after handling soiled items or before providing care to residents. Hand sanitizer dispensers in the hallway were found to be empty, and the ADON explained that hand sanitizer is sometimes removed due to residents eating it. The ADON provided hand hygiene education materials, but they were incomplete and lacked signatures. A facility policy on hand hygiene was requested but not provided by the completion of the survey.
Failure to Provide Appropriately Sized Bed for Resident
Penalty
Summary
The facility failed to provide an appropriately sized bed for a resident, identified as R255, who was six feet, four inches tall and had diagnoses including Parkinson's Disease and Dementia. Observations over several days revealed that the resident's feet were consistently resting on the footboard of the bed, indicating that the bed was too small to accommodate their height. The resident expressed discomfort and a preference for a bed that would better fit their stature, as they were only able to fit on the mattress by bending their legs. Further observations showed that the resident was unable to adjust themselves in the bed independently due to the manual nature of the bed adjustments, which lacked a remote control. The Assistant Director of Nursing acknowledged that the expectation was for residents to have beds that fit their bodies and that direct care staff should have identified and addressed the issue. The facility's policy on Accommodation of Needs and Preferences emphasized the importance of creating an individualized, home-like environment to maintain the resident's dignity and well-being, which was not met in this case.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to investigate two separate incidents of alleged abuse involving residents and staff. In the first incident, a resident was reportedly pulled from their wheelchair by another resident, resulting in a fracture. Despite the severity of the injury and the resident's impaired cognition, the facility did not conduct a thorough investigation to determine the exact circumstances of the altercation. The Nursing Home Administrator was unable to provide clarity on the incident, and no statements were collected from involved parties. In the second incident, a resident alleged that they were choked by a staff member during an altercation. The resident's neck appeared red, and a picture was taken by another staff member who reported the incident. However, the facility did not document the incident in the resident's medical record, nor did they report it to the state agency as required. The Nursing Home Administrator admitted to not conducting a proper investigation and failing to report the incident. The facility's policy mandates immediate investigation and reporting of abuse, but these procedures were not followed in either case. The lack of documentation, investigation, and reporting highlights significant deficiencies in the facility's handling of abuse allegations, potentially compromising resident safety and compliance with state and federal regulations.
Failure to Develop Care Plan for Aggressive Behavior
Penalty
Summary
The facility failed to develop a comprehensive care plan to address aggressive behaviors for a resident with a history of such behaviors. The resident, diagnosed with dementia and exhibiting moderate cognitive impairment, was involved in multiple incidents of verbal and physical aggression towards staff and other residents. These incidents were documented in the resident's progress notes over several months, indicating a pattern of aggressive behavior that included verbal aggression, physical aggression, and refusal of care. Despite these documented behaviors, the resident's care plan did not include any interventions or strategies to manage or mitigate the aggressive behavior. The deficiency was highlighted when another resident reported being pulled out of their wheelchair by the aggressive resident, leading to concerns about safety and the lack of appropriate interventions. The Assistant Director of Nursing acknowledged the absence of a care plan addressing the aggressive behavior, despite the resident's known history. This oversight in care planning represents a failure to meet the resident's needs and ensure the safety of both the resident and others in the facility.
Failure to Provide Consistent Oral Care for a Dependent Resident
Penalty
Summary
The facility failed to provide proper oral care for a resident, identified as R83, who was dependent on staff for activities of daily living (ADLs) due to cognitive impairment and a history of bacterial meningitis and aphasia. Over several days, observations revealed that R83's mouth was consistently dry, and their teeth were coated with a noticeable layer of white residue. Despite R83's need for assistance with oral hygiene, as confirmed by both the resident and staff interviews, the necessary care was not provided. R83 reported not having brushed their teeth for about 4 or 5 days, and their oral condition remained unchanged across multiple observations. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and a Certified Nurse Assistant (CNA), confirmed that R83 required help with oral care. The CNA stated that R83 received oral care only when they were assigned to them, indicating inconsistency in care provision. The Assistant Director of Nursing (ADON) acknowledged that dependent residents should receive daily oral hygiene and that any refusal should be documented. However, there was no documentation of refusal, and the facility failed to provide a policy on ADL care upon request, highlighting a deficiency in ensuring consistent oral care for R83.
Failure to Provide Proper Wound Care
Penalty
Summary
The facility failed to provide appropriate wound care treatment for a resident with a wound on the third toe of their right foot. Observations over several days revealed that the bandage on the wound was not changed, despite the resident indicating it had been there for too long. The resident was observed in various locations, including in bed and in a gerichair, with the same unchanged bandage. A Certified Nurse Assistant was seen putting a sock over the wound without changing the bandage. The resident's medical records indicated orders for specific wound care treatments, including soaking the foot and applying antibiotic with a dry dressing, which were not followed. Interviews with facility staff, including a wound care nurse and the Assistant Director of Nursing, revealed a lack of awareness and adherence to the prescribed wound care orders. The wound care nurse incorrectly stated that the resident did not have any wounds and admitted to only performing treatments as needed, rather than as ordered. Additionally, the whirlpool tub required for the treatment was found to be unusable, filled with bags of linen and other belongings. The facility's wound care policy was requested but not provided by the end of the survey.
Failure to Document and Offer Vaccinations
Penalty
Summary
The facility failed to document or offer influenza or pneumonia vaccinations for two residents, R23 and R305, out of five reviewed. R23 was admitted with intact cognition, as indicated by a mental status score of 15, but there were no vaccine consents or records of vaccines being offered or provided. The Assistant Director of Nursing (ADON) was unable to explain how this oversight occurred. For R305, the medical record showed a consent signed by the resident's guardian for both vaccines, but the vaccinations were documented as refused by the resident. Although a progress note indicated that the resident was educated about the vaccines, there was no documentation that the guardian was informed of the resident's refusal.
Failure to Offer and Document COVID-19 Vaccine for a Resident
Penalty
Summary
The facility failed to offer and document the COVID-19 vaccine for a resident identified as R23. During an interview with the Assistant Director of Nursing (ADON) on August 28, 2024, it was discovered that R23's medical record did not contain any COVID-19 vaccine consents, nor was there any indication that the vaccine had been offered or administered. R23 was admitted to the facility with a mental status score of 15, indicating intact cognition, which suggests that the resident was capable of making informed decisions regarding vaccination. The ADON was unable to explain how this oversight occurred, indicating a lapse in the facility's vaccination protocol for this resident.
Inadequate Room Size in Multiple Resident Rooms
Penalty
Summary
The facility failed to provide the required minimum square footage of living space per bed in multiple resident rooms, as observed during an environmental tour conducted by the surveyor. Specifically, 21 out of 36 rooms did not meet the standard of 80 square feet per bed for multiple resident rooms. The rooms in question included various configurations, such as 3-bed wards with only 216 square feet and 4-bed wards with as little as 272 square feet, all falling short of the required space. This deficiency was identified through direct measurements of the rooms, which revealed that the space allocated per resident was insufficient according to regulatory standards. Despite the spatial inadequacies, residents interviewed in the affected rooms expressed that they were not impacted by the current room sizes. The facility's policy on Resident Rights, dated 11/28/17, emphasizes the importance of providing a safe, clean, comfortable, and homelike environment that supports resident independence. However, the observed room sizes contradict this policy, as they do not provide the mandated space necessary to ensure a comfortable living environment for the residents.
Latest citations in Michigan
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
