The Villa At West Branch
Inspection history, citations, penalties and survey trends for this long-term care facility in West Branch, Michigan.
- Location
- 445 South Valley Street, West Branch, Michigan 48661
- CMS Provider Number
- 235414
- Inspections on file
- 23
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Villa At West Branch during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in medication storage and labeling, including medications and insulin pens lacking required expiration dates after opening, missing open dates, loose tablets in medication carts, and expired medical supplies in the medication room. Additionally, a medication cart was left unlocked and unattended with resident information visible, and some medication containers were missing lids or not stored in original packaging. These issues were confirmed by nursing staff and the DON.
Surveyors found that staff failed to follow food safety and sanitation procedures, including not wearing hairnets, not washing hands before food preparation, storing open staff beverages in the kitchen, and preparing food on visibly soiled surfaces. Expired and improperly stored food items were found in refrigerators and freezers, with inadequate temperature monitoring and significant ice build-up. Staff and leadership demonstrated inconsistent understanding and enforcement of facility food safety policies, affecting all residents receiving kitchen-prepared meals.
The facility did not maintain a comprehensive infection control program, with incomplete infection tracking, inconsistent antibiotic stewardship, and lack of process surveillance. Additionally, a resident's urinary catheter drainage bag and tubing were repeatedly observed on the floor, and staff failed to follow proper infection control procedures when handling the catheter.
Three medication errors were observed, resulting in an 8% error rate. Incidents included an IV antibiotic left hanging in a resident's room for several hours before administration by a different LPN, medications left at a resident's bedside without proper orders, and levothyroxine given with breakfast instead of on an empty stomach. These events were confirmed through staff interviews and record reviews, showing non-compliance with medication administration policies.
The facility did not ensure that arbitration agreements were explained in a way that residents or their representatives could understand. Several cognitively intact residents who signed the agreements could not recall or describe what they had signed, and none of the residents attending a council meeting understood the arbitration process. This resulted in residents being unsure of their rights regarding the arbitration agreement.
Surveyors found that several residents with urinary catheters were not treated in a dignified manner, as their urine collection bags were left uncovered or with tubing on the floor, despite the facility having privacy covers available. In some cases, staff were unaware of the catheter's status or did not use appropriate PPE when handling the equipment, and residents expressed confusion or dissatisfaction with their care.
A resident with severe cognitive impairment and a formal determination of incompetency was allowed to sign their own advance directive (MI-POST) form, rather than having it completed by the designated patient advocate. Staff interviews confirmed this was an error, as facility policy requires advance directives to be completed by a responsible party when a resident is deemed incompetent.
A resident with severe cognitive and physical impairments was not provided with shaving and personal hygiene care according to their preferences. Staff and documentation confirmed that shaving was only performed on shower days, despite the resident's stated desire to be clean-shaven more frequently. The care plan and facility procedures did not address the resident's individual needs or preferences for ADL care.
Three residents received inappropriate respiratory care due to staff not following physician orders for oxygen administration, failing to update care plans, and not maintaining oxygen equipment in a sanitary manner. One resident used a nebulizer that was not cleaned after use, another received oxygen at a rate inconsistent with the physician's order and care plan, and a third had access to oxygen equipment without a physician's order or documentation, with therapy staff administering oxygen based on verbal direction.
A resident with multiple medical conditions was found using bed rails without a provider order, assessment, or informed consent, despite facility policy requiring these steps. Staff confirmed the absence of required documentation and assessments for bed rail use, and the care plan did not specifically address the use of bed rails.
The facility did not provide meals according to the posted menu and failed to inform residents of food substitutions. A resident received hot dogs instead of the scheduled bratwurst, leading to visible distress and complaints about frequent unannounced menu changes. Multiple residents confirmed that substitutions were common and not communicated in advance, resulting in frustration and dissatisfaction with meal service.
The facility failed to implement and operationalize policies for pressure ulcer prevention and management, resulting in the development and worsening of pressure ulcers for four residents. One resident developed a Stage 3 pressure ulcer that deteriorated to an unstageable wound, while another resident's pressure ulcer became infected, leading to hospitalization. The facility did not provide timely interventions, adequate documentation, or investigate contributing factors, causing significant harm to the residents.
A resident with a history of anemia, chronic kidney disease, diabetes, and heart disease experienced severe rectal injuries after an improperly administered enema at an LTC facility. Despite having multiple bowel movements prior, the facility failed to document a clinical rationale for the enema and did not follow established bowel protocols. The resident suffered multiple anal mucosa tears and a full-thickness rectal tear, requiring surgical repair. The facility delayed calling emergency services despite the resident's complaints of pain and requests for hospital transfer.
The facility failed to adhere to food safety standards, including improper labeling and dating of food items, inadequate temperature control of cold and hot foods, and potential cross-contamination during meal preparation. Additionally, moldy bread was found in the nourishment room, indicating lapses in infection control monitoring.
The facility failed to ensure accurate code status documentation for six residents, resulting in conflicting and incomplete DNR orders. The DNR forms lacked clearly delineated physician signatures, and one resident's records contained both DNR and Full Code orders, leading to confusion about the resident's actual code status.
The facility failed to ensure accurate dispensing, administration, and reconciliation of controlled substances, resulting in discrepancies in narcotic medication counts and improper storage of an unlabeled syringe containing morphine. The DON confirmed the inaccuracies and acknowledged the issues with medication management.
The facility failed to implement a comprehensive infection control program, resulting in inadequate infection tracking and monitoring, and lacked functioning hand hygiene equipment. Additionally, a nurse administered medications in an unsanitary manner, leading to cross-contamination.
The facility failed to ensure planned fall prevention interventions were in place for a resident with a history of stroke and Alzheimer's disease. Despite the care plan requiring fall mats on both sides of the bed, observations revealed that only one side had a fall mat, increasing the risk of injury.
The facility failed to change a urinary catheter as per physician's orders for a resident, leading to recurrent UTIs. The resident's medical records revealed multiple missed catheter changes, contributing to several infections and hospitalizations. Interviews and records confirmed the lapses in catheter management and the resulting health complications.
A resident with a stage IV pressure ulcer received Rocephin antibiotic therapy for 7 days before wound culture results showed no susceptibility to the antibiotic. Despite the culture revealing MRSA and Streptococcus Agalactiae, the resident continued to receive Rocephin without any adjustment to the antibiotic regimen.
The facility failed to justify the use of PRN antianxiety medication and document the rationale for indefinite use for two residents, resulting in the likelihood of unnecessary medications and adverse effects. Orders for Ativan and Xanax were found to be indefinite without a 14-day stop date, contrary to facility policy.
The facility failed to maintain a medication error rate below 5%, resulting in a 7.4% error rate. A resident was left unattended during a nebulizer treatment, and another resident received incorrect insulin administration. Staff were unaware of the proper procedures.
The facility failed to submit PBJ data on time for the second quarter of 2023, leading to CMS triggering staffing concerns for low weekend staffing in the fourth quarter. Additionally, the posted nursing staffing information was not easily readable, which could hinder effective communication and staffing management.
A resident with a stage IV pressure ulcer received ceftriaxone sodium (Rocephin) for a wound infection without appropriate clinical rationale. The wound culture results did not recommend Rocephin, and the facility's policies on infection surveillance and antibiotic stewardship were not followed, leading to inappropriate antibiotic use.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in medication storage and labeling practices across several medication carts and a medication room. Medications, including multi-dose vials, insulin pens, and eye drops, were found without required expiration dates after opening, despite facility policy mandating that opened medications be dated and assigned a new expiration date. Some medications were missing open dates entirely, and loose tablets were found in medication cart drawers. Additionally, a medication cart was left unlocked and unattended with a computer screen displaying resident medical information, contrary to facility policy requiring carts to be locked when not in direct supervision. Further observations revealed expired medical supplies, such as povidone iodine and bleach wipes, stored in the medication room. There were also instances of medication containers missing lids and multi-dose ampules not stored in their original packaging or properly dated. These findings were confirmed through interviews with nursing staff and the Director of Nursing, who acknowledged the lapses in medication storage and administration procedures.
Deficient Food Safety and Sanitation Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food safety and sanitation procedures. Upon entering the kitchen, staff were not wearing hairnets as required, and there was confusion about where hairnets should be located and when they should be worn. Staff were seen entering food preparation areas without washing their hands, and open, uncovered staff beverages were stored on a shelf in the dishwashing area. The food preparation table was visibly soiled with food debris and crumbs, and staff were preparing resident meals on this unclean surface. Additionally, the sanitizer bucket used for cleaning was found to have zero parts per million of sanitizer, far below the required level, and was not kept in the food preparation area for easy access. Further inspection of food storage revealed several expired food items in both the refrigerator and freezer, including ham, sour cream, diced chicken, and canola oil. Some food items, such as individual ice cream cups, were not frozen solid, and there was no thermometer inside the freezer to monitor temperature. Freezer and refrigerator organization was poor, with food stored directly on the floor, significant ice build-up, and icicles present. Thawing meat was placed on top of boxes of produce, and containers of whipped topping were found with greasy substances on their surfaces. Staff were unclear about proper storage procedures and expiration dates, and the maintenance schedule for defrosting the freezer was unknown. Interviews with the Administrator, DON, and Infection Control LPN revealed a lack of consistent understanding and enforcement of food safety policies, including the use of hairnets and the prohibition of personal beverages in food preparation areas. Facility policies required hairnets to be worn at all times in the kitchen and specified proper hand hygiene, food storage, and temperature monitoring, but these were not being followed. The observed deficiencies affected all residents who consumed food prepared in the kitchen, creating the potential for food contamination and foodborne illness.
Failure to Implement Comprehensive Infection Control Program and Maintain Catheter Care Standards
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection prevention and control (IC) program, as evidenced by incomplete and inconsistent infection surveillance, inaccurate infection tracking, and lack of data monitoring and analysis. The IC LPN responsible for the program had less than a month of experience in infection control and was unfamiliar with key aspects of the role. Discrepancies were found between the infection mapping tool and the monthly infection control log, with infections missing or misclassified, and no system in place to track resident discharges, room changes, or carryover infections from previous months. Additionally, the facility did not track potential infections that were not treated with antimicrobials, and the IC LPN was unfamiliar with process surveillance and had not completed required audits. Further review revealed that antibiotic stewardship practices were not consistently followed. Several residents received antibiotics without appropriate culture and sensitivity (C&S) testing, and documentation was lacking regarding the rationale for antibiotic use when criteria were not met. In some cases, antibiotics were administered based solely on physician orders, without evidence of infection or proper risk versus benefit analysis. The facility's infection control policy required a system for monitoring antibiotic use, but this was not operationalized in practice. Direct observation of a resident with a urinary catheter revealed that the catheter drainage bag and tubing were repeatedly found lying on the floor, both inside and outside the privacy bag. The resident was unaware of the catheter's management, and staff who entered the room did not address the issue until prompted by a surveyor. When the LPN picked up the catheter from the floor, they did so without enhanced barrier personal protective equipment (PPE). These lapses in infection control practices created the potential for environmental contamination and the spread of infection among residents.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as three medication errors were observed out of 25 opportunities, resulting in an 8% error rate. One incident involved an intravenous (IV) antibiotic, Meropenem, which was mixed by an LPN during the night shift and left hanging in a resident's room from approximately 6:00 AM until after 11:00 AM, when it was administered by another LPN. The medication was signed out as given at 6:00 AM, despite not being administered until much later. Both LPNs involved acknowledged the delay and improper handling of the medication, with the IV bag left unattended in the resident's room for several hours. Another incident involved a resident who had three white tablets and a green Tums tablet left at the bedside by the night nurse, despite no physician order for Tums and no standing order for medications to be left at the bedside. The resident reported that the night nurse provided the tablets to moisturize her mouth. Additionally, levothyroxine was administered to the same resident with breakfast and other medications, contrary to guidelines that require it to be given on an empty stomach. These actions were observed and confirmed by staff interviews and record reviews, demonstrating non-compliance with the facility's medication administration policies.
Failure to Adequately Explain Arbitration Agreements to Residents
Penalty
Summary
The facility failed to ensure that binding arbitration agreements were explained in a manner that could be understood by residents or their representatives. Interviews with the nursing home administrator and admissions director confirmed that while the arbitration agreement was presented and residents were told it was not required for admission, several cognitively intact residents who had signed the agreement were unable to explain or recall what the arbitration agreement was. Specifically, three residents with high BIMS scores, indicating cognitive intactness, could not describe or remember the arbitration agreement they signed, and one stated it was not explained to her. Additionally, during a resident council meeting, all six residents in attendance reported not understanding the arbitration process or what the agreement meant. One resident expressed that the volume of information provided during admission made it difficult to remember what was signed, and another cited a lack of trust. The findings indicate that the facility did not adequately ensure residents or their representatives were informed about the arbitration agreement or their right to refuse, resulting in a lack of understanding among those who signed.
Failure to Maintain Resident Dignity with Urinary Catheter Management
Penalty
Summary
Surveyors identified that the facility failed to ensure residents with urinary catheters were treated in a dignified manner, as evidenced by uncovered urine collection bags and lack of respect for residents' individuality. One resident with an indwelling urinary catheter was observed multiple times with an uncovered urine collection bag, both in their room and in the dining area, despite the facility having dignity bags and covered collection bags available. The DON confirmed that these covers should be used and are accessible to staff. Another resident was observed with a urinary catheter and tubing lying on the floor outside of the privacy bag, both at bedside and while awaiting a meal. The resident was unaware of the catheter's status, and an LPN, when notified, picked up the catheter from the floor without enhanced barrier PPE, stating uncertainty about why the catheter was out of the privacy bag. A third resident was initially observed with a visible urinary catheter and urometer from the doorway, with no privacy bag in place. The resident reported being new to the facility and expressed concerns about staff responsiveness. The following day, a privacy bag was in place, and the resident stated that staff had added the cover the previous afternoon, after the catheter had been visible to others. These observations demonstrate that the facility did not consistently maintain resident dignity regarding the management and privacy of urinary catheters.
Plan Of Correction
F550(D) Resident Rights/Exercise of Rights Residents 4, 108, and 208, all have catheter dignity bags or leaf covered catheter bags and have been verified that they are being used appropriately to maintain residents' rights and dignity. Any resident with a catheter could be affected by this. Residents with catheters have all been reviewed and verified to have dignity bags or leaf covered catheter bags. Any concerns identified were immediately corrected. The Residents Rights guideline was reviewed and deemed appropriate by the NHA and DON. The DON/Designee will educate all staff on the guideline and the need to treat residents with dignity and respect by keeping their catheters covered with a dignity bag or a leaf covered bag. The DON/Designee will audit all catheters 3x/weekly for 4 weeks and until substantial compliance is achieved to verify that all catheters are covered with appropriate dignity device. The results of these audits will be reviewed by the facility Quality Assurance Performance Improvement (QAPI) committee for patterns, trends, and continued recommendations for process monitoring and continued improvement.
Advance Directive Signed by Incompetent Resident
Penalty
Summary
The facility failed to ensure that advance directive forms were properly completed by a designated responsible party for a resident who was deemed incompetent to make medical decisions. The resident, who had diagnoses including dementia and a history of falls, was assessed as severely cognitively impaired and required substantial to maximum assistance. Documentation in the medical record indicated that the resident was admitted to hospice services and had been formally evaluated as incompetent to make healthcare decisions by both a physician and a clinical psychologist. Despite this determination of incompetency, the most recent advance directive form specifying code status (MI-POST) was signed by the resident, rather than by the designated patient advocate or responsible party. Interviews with facility staff confirmed that the resident should not have signed the form due to their incompetency, and the error was attributed to a likely mistake by nursing staff. The facility's policy requires periodic evaluation of residents' decision-making capacity and proper completion of advance directives, which was not followed in this instance.
Failure to Provide ADL Care According to Resident Preference
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, paralysis, and a history of heart disease and strokes was not provided with personal hygiene care according to their preferences. The resident was observed on multiple occasions to have an unshaven face and an unkempt appearance, despite expressing a preference to be clean-shaven. Interviews with staff confirmed that shaving was only performed on shower days, which was the facility's usual procedure, rather than according to the resident's stated preference. The resident's care plan indicated a need for assistance with personal hygiene due to significant physical and cognitive limitations. Documentation reviewed did not specify shaving as a separate hygiene task, and the Director of Nursing stated that the resident could request to be shaved, without addressing the impact of the resident's cognitive impairment on their ability to make such requests. This failure to provide ADL care in accordance with the resident's preferences and needs led to the identified deficiency.
Failure to Follow Physician Orders and Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not following physician's orders for oxygen administration, not updating care plans to reflect current oxygen orders, and not maintaining oxygen supplies in a sanitary manner. One resident, with COPD and other comorbidities, was observed completing a nebulizer treatment independently, after which a nurse placed the used nebulizer mask and tubing with medication residue into a plastic bag without cleaning or drying the equipment. This was confirmed by both the nurse and the Director of Nursing. Another resident with COPD and chronic respiratory failure was observed receiving oxygen at a rate different from the physician's order. The electronic medical record indicated an order for continuous oxygen at 4LPM, but the concentrator was set to 3LPM. Additionally, after the order was updated to allow a range of 2LPM-4LPM, the care plan and Kardex still reflected the previous order of 4LPM continuous, resulting in inconsistent documentation and care instructions. A third resident, with a history of CHF and other conditions, was found with an oxygen concentrator and nasal cannula tubing in their room, despite having no physician's order or care plan for supplemental oxygen. The tubing was undated, uncontained, and showed signs of use. Therapy staff reported that the resident had been given oxygen during therapy sessions at the direction of nursing staff, but there was no documentation or order for this intervention in the resident's medical record.
Failure to Follow Bed Rail Assessment and Documentation Procedures
Penalty
Summary
The facility failed to implement and operationalize its policies and procedures regarding bed rail use for one resident. The resident was observed in bed with side rails present, but there was no evidence in the medical record of a health care provider order, assessment, or monitoring for the use of bed rails. The facility's own policy requires a physician order, initial and ongoing assessments, informed consent, and documentation of risks and benefits before bed rails are used, none of which were found in this case. The resident involved had a history of left lower limb monoplegia, schizophrenia, depression, and traumatic brain injury, and was cognitively intact but required assistance with activities of daily living. The care plan referenced a previous fall and included education on the use of half rails and call lights, but there was no separate or current care plan specifically addressing bed rail use. Documentation showed that after a fall, the resident was educated on using side rails for bed mobility, but no formal assessment, consent, or provider order was documented. Interviews with the DON and a clinical RN confirmed that the required documentation, including a physician order and assessment for bed rail use, was missing from the resident's record. The facility's policy outlines a comprehensive process for evaluating and documenting bed rail use, including alternatives, risk assessment, and informed consent, but these steps were not followed for this resident.
Failure to Follow Menus and Notify Residents of Meal Substitutions
Penalty
Summary
The facility failed to provide meal items as listed on the menu and did not notify residents of menu changes. During a kitchen tour, staff were observed preparing hot dogs for lunch, although the menu specified bratwurst on a bun. One resident received hot dogs instead of the expected bratwurst and expressed disappointment and frustration, stating that not receiving the planned menu items was a frequent occurrence. The resident became visibly upset upon receiving the incorrect meal and reported that this issue happened often. A review of the facility's menu confirmed that hot dogs were not listed as the lunch item for that day. Additionally, during a resident council meeting, all six residents present confirmed that food substitutions were often made without prior notification. This lack of communication and failure to follow the planned menu led to residents feeling frustrated and discontent with the meals provided.
Failure to Implement Pressure Ulcer Prevention and Management Policies
Penalty
Summary
The facility failed to implement and operationalize policies and procedures for pressure ulcer prevention and management, resulting in the development and worsening of pressure ulcers for four residents. Resident #9, who had multiple diagnoses including Multiple Sclerosis and paraplegia, developed a Stage 3 pressure ulcer on their right posterior thigh while at the facility. Despite being at high risk for pressure ulcer development, the resident did not receive timely and appropriate interventions such as an alternating pressure mattress or regular repositioning. The resident's pressure ulcer deteriorated to an unstageable wound with necrotic tissue and tunneling, causing significant pain and discomfort. Staff failed to document and implement necessary care interventions, and the resident was often left in their electric wheelchair for extended periods without repositioning, contrary to care plan instructions. Additionally, the facility did not investigate the suitability of the resident's wheelchair cushion for pressure reduction, despite concerns that it may have contributed to the pressure ulcer development. Resident #59, who was admitted with a right femur fracture and other conditions, developed a pressure ulcer that became infected while at the facility. The resident's family members, including a nurse, discovered the pressure ulcer and informed the facility staff, who were unaware of its existence. The resident's condition worsened, with an elevated white blood cell count indicating infection, and the resident was eventually transferred to the hospital. Documentation revealed inconsistencies and a lack of timely interventions for the pressure ulcer, including the absence of a specialty mattress and regular repositioning. The facility's records did not include necessary wound care orders or treatments for the pressure ulcer, and staff failed to document and address the resident's pain and skin integrity concerns adequately. The facility's failure to adhere to its own policies and procedures for pressure ulcer prevention and management resulted in significant harm to the residents. The lack of timely and appropriate interventions, inadequate documentation, and failure to investigate and address potential contributing factors led to the development and worsening of pressure ulcers, causing unnecessary pain and suffering for the residents involved.
Inadequate Bowel Assessment and Enema Administration Leads to Resident Injury
Penalty
Summary
The facility failed to adequately assess and monitor a resident's bowel condition, leading to inappropriate medical intervention. The resident, who was cognitively intact and had a history of anemia, chronic kidney disease, diabetes, and heart disease, experienced constipation and rectal bleeding. Despite having multiple bowel movements prior to the incident, the facility did not document a clinical rationale for administering an enema, nor did they follow the established bowel protocol. The resident requested an enema, which was administered by a nurse who expressed discomfort with the procedure. The nurse encountered resistance during the enema administration and repeatedly inserted the enema tip, causing significant injury to the resident's rectal area. The resident experienced severe pain during the procedure and subsequently suffered from multiple anal mucosa tears and a full-thickness rectal tear, requiring surgical repair. Despite the resident's complaints of pain and requests to be sent to the emergency room, the facility delayed calling emergency services for several hours. The resident's condition deteriorated, necessitating a transfer to a hospital where he received blood transfusions and underwent surgery for rectal injuries. Interviews with the nursing staff revealed a lack of proper assessment and documentation regarding the resident's condition and the enema procedure. The nurses involved were deemed competent in enema administration and change of condition assessments, yet failed to adhere to facility protocols and policies. The Director of Nursing acknowledged discrepancies in the accounts of the incident and the failure to perform necessary assessments prior to the resident's transfer to the emergency room.
Food Safety and Temperature Control Deficiencies
Penalty
Summary
The facility failed to adhere to food safety standards, resulting in multiple deficiencies observed by surveyors. Food items in the kitchen were not properly dated or labeled, including beverages, sandwiches, and other prepared foods. Additionally, pasteurized eggs in the walk-in cooler were not marked with an expiration date, and the Dietary Director was unsure of their shelf life. During meal preparation, the cook did not clean the thermometer between checking different food items, and the thermometer was not sanitized after falling into a gravy mixture. Furthermore, the cook did not change gloves after handling different food items, leading to potential cross-contamination. The surveyors also observed that cold beverages were not kept at safe temperatures, with milk being served at 51.6 degrees Fahrenheit, well above the recommended maximum of 41 degrees Fahrenheit. Hot food items were also found to be at unsafe temperatures, with biscuits and gravy served at 97.5 degrees Fahrenheit. The facility's 'Food Safety Requirements Guideline' policy clearly states the danger zone for food temperatures, which was not adhered to during these observations. In the nourishment room, a loaf of wheat bread was found to be moldy, despite being marked with a date indicating it was recently received. The Licensed Practical Nurse/Unit Manager/Infection Control Preventionist acknowledged that infection control rounds were conducted monthly, but the moldy bread indicated a lapse in monitoring. The Dietary Director confirmed that the bread was used to make sandwiches, further highlighting the risk of contamination. The facility's failure to maintain proper food safety protocols and temperature controls poses a significant risk to the health and safety of its residents.
Inaccurate Code Status Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of code status documentation for six residents, resulting in conflicting and incomplete Do Not Resuscitate (DNR) orders. Resident #4's DNR form lacked a clearly delineated physician signature, despite being signed by the resident and two witnesses. Similarly, Resident #8's DNR form was signed by the responsible party and only one witness, with no physician signature. Resident #36, Resident #29, and Resident #40 also had DNR forms that were signed by the residents and two witnesses but lacked a clear physician signature, with the physician signing as a witness instead. This inconsistency voided the residents' wishes for their DNR status as per the Michigan Do-Not-Resuscitate Procedure Act requirements. Additionally, Resident #22's records contained conflicting code status documentation, with both DNR and Full Code orders active, leading to confusion about the resident's actual code status. During the initial tour, Resident #4 was observed to be self-propelling in a wheelchair and in good spirits, while Resident #8 was resting in bed. Resident #36, Resident #29, and Resident #40 were also reviewed, revealing similar issues with their DNR forms. The facility's DNR forms did not have a specific signature line for the physician, leading to the physician signing as a witness instead. This issue was confirmed during interviews with the Social Work Director, Director of Nursing (DON), and Regional Clinical Nurse, who acknowledged the lack of a separate physician signature line on the DNR forms. Resident #22's case highlighted the confusion caused by conflicting code status documentation. The resident's electronic medical record showed both DNR and Full Code orders, with no care plan addressing the advanced directive. The Unit Manager confirmed the discrepancy and clarified the code status with the resident, who elected to continue as a Full Code. A new advanced directive form was signed, but the initial conflicting documentation indicated a failure to ensure accurate code status records for the resident.
Failure to Ensure Accurate Controlled Substance Management
Penalty
Summary
The facility failed to implement and operationalize policies and procedures to ensure accurate dispensing, administration, and reconciliation of controlled substances. During a tour of the C Hall Number Two Medication cart, an unlabeled oral syringe containing 0.25 mL of a light blue substance, identified as morphine, was found improperly stored. The Registered Nurse (RN) on duty was unaware of the syringe's presence and could not explain the discrepancies in the narcotic medication counts. The morphine bottle for a resident was found to contain 15 mL instead of the documented 16 mL. Additionally, discrepancies were found in the counts of Ativan, Xanax, and Gabapentin for other residents, with the RN admitting to not signing out three of the four pills administered and being unable to explain the fourth discrepancy. The Director of Nursing (DON) was informed of the findings and confirmed the inaccuracies in the medication counts. The DON acknowledged that the presence of the unlabeled syringe and the discrepancies in the controlled substance counts were not acceptable. The facility's policy and procedure documents related to medication administration and controlled medication storage and reconciliation were requested but not provided by the conclusion of the survey. The failure to maintain accurate records and proper storage of controlled substances poses a risk of medication errors and potential diversion of narcotics.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection control program, which included outcome and process surveillance, accurate data collection, and analysis. This resulted in a lack of accurate and comprehensive infection control tracking, surveillance, and data monitoring/analysis. Additionally, there was a lack of accessibility to hand hygiene supplies and functioning equipment, increasing the likelihood of microorganism spread and illness among all 56 facility residents. Specific observations included a non-functioning hand sanitizer dispenser in a resident's room and a broken soap dispenser in a communal bathroom, which were not promptly addressed by the maintenance and environmental services staff. Interviews with the Infection Control (IC) Licensed Practical Nurse (LPN) revealed significant gaps in the infection control program, including the absence of process surveillance for hand hygiene and environmental surveillance in resident rooms. The IC LPN was unaware of the issues with hand hygiene equipment and did not have a comprehensive system for tracking and monitoring infections. The data provided for infection surveillance was inconsistent and incomplete, with discrepancies in the line listings, summaries, and mapping tools. The IC LPN also lacked knowledge about the criteria for treating infections and the proper documentation of infection symptoms and treatments. Additionally, the facility failed to administer medications in a sanitary manner. During a medication pass task, a nurse placed two narcotics directly on top of the medication cart, which led to cross-contamination of oral medications. The nurse attempted to rectify the situation by placing the pills in a medication cup and administering them to a resident, but this action did not adhere to proper sanitary protocols. This incident further highlights the facility's deficiencies in maintaining a sanitary environment and preventing the spread of infections.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that planned interventions for fall prevention were in place for Resident #14. On multiple observations, it was noted that the resident's bed had a fall mat only on the left side, despite the care plan indicating that fall mats should be on both sides of the bed. This discrepancy was observed on 5/06/24 and 5/08/24, and confirmed during an observation with the Unit Manager on 5/09/24. The Unit Manager acknowledged that the resident had bilateral fall mats before moving rooms but did not respond when alerted that the second fall mat was missing during the survey period. Resident #14, who was admitted on 4/20/2020, has a medical history that includes stroke, difficulty in walking, and Alzheimer's disease. The resident is at high risk for falls due to gait and balance problems, hemiparesis on the right side, and Alzheimer's disease. The care plan, initiated on 4/28/23, specified the use of fall mats on both sides of the bed to prevent injury. However, this intervention was not consistently implemented, as evidenced by the observations made during the survey.
Failure to Change Urinary Catheter Leading to Recurrent UTIs
Penalty
Summary
The facility failed to change a urinary catheter as per physician's orders for a resident, leading to recurrent urinary tract infections (UTIs). The resident's medical records revealed multiple instances where the catheter was not changed on the scheduled dates, as indicated by the physician's orders. For example, the catheter change scheduled for September 2023 was not performed, and there were no records of catheter changes in November 2023, December 2023, February 2024, March 2024, and April 2024. This non-compliance with the catheter change schedule contributed to the resident experiencing multiple UTIs over several months, requiring various antibiotic treatments, including Rocephin, Bactrim, and Keflex. The resident's condition was further complicated by hospitalizations due to sepsis and infections with multiple organisms, including Proteus Mirabilis, Citrobacter Freundii, Pseudomonas Aeruginosa, and Enterococcus Faecalis. The facility's failure to adhere to its own 'Urinary Indwelling Catheter Management Guideline' and 'Urinary Tract Infections/Bacteriuria-Clinical Protocol' policies was evident in the lack of consistent catheter care and timely changes. Interviews with the Licensed Practical Nurse/Infection Control Preventionist/Unit Manager (LPN/ICP/UM) confirmed the recurrent UTIs and the lapses in catheter management. The facility's infection control logs and treatment administration records further corroborated the deficiencies in catheter care and the resulting health complications for the resident.
Improper Antibiotic Therapy for Wound Infection
Penalty
Summary
The facility failed to provide proper antibiotic therapy for a resident with a wound infection. The resident, who had bilateral lower limb amputations and a stage IV pressure ulcer, received Rocephin antibiotic therapy for 7 days prior to the wound culture results. The wound culture, collected on the same day the antibiotic therapy started, revealed the presence of Methicillin Resistant Staphylococcus Aureus (MRSA) and Streptococcus Agalactiae, with no susceptibility to Rocephin. Despite this, the resident continued to receive Rocephin for the entire 7-day course without any adjustment to the antibiotic regimen based on the culture results. The facility's Medication Therapy policy emphasizes that medication use should be consistent with an individual's condition and diagnostic test results. However, the review of the resident's Medication Administration Record (MAR) and wound culture report indicated that the prescribed antibiotic was not appropriate for the identified organisms. The Licensed Practical Nurse (LPN) and Infection Control Preventionist confirmed that no other antibiotic was ordered post wound culture results, leading to the resident receiving an ineffective treatment for the wound infection.
Failure to Justify and Document PRN Antianxiety Medication Use
Penalty
Summary
The facility failed to justify the use of PRN antianxiety medication and document the rationale for indefinite use for two residents, resulting in the likelihood of unnecessary medications and adverse effects. For Resident #46, the physician's order for Ativan 1mg every 4 hours as needed was found to be indefinite without a 14-day stop date. Additionally, the order was changed to every 2 hours as needed indefinitely without proper documentation. The Corporate Clinical Consultant acknowledged the oversight and indicated that the order would be corrected to include a 14-day stop date. For Resident #48, the physician's order for Xanax 0.5mg every 4 hours as needed for anxiety was also found to be indefinite without a 14-day stop date. The medication was administered 32 times in April and 12 times in May, exceeding the 14-day limit. The Social Services Director confirmed the oversight during an interview. The facility's policy mandates that PRN psychotropic medication orders be discontinued after 14 days unless re-evaluated by the attending physician, which was not adhered to in these cases.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure a medication error rate less than 5%, resulting in a medication error rate of 7.4%. This was observed in two residents out of 27 observations. Resident #7 was left unattended while receiving a nebulizer treatment, which is against the facility's policy. The resident was heard coughing and was found with minimal mist in the nebulizer mask, indicating improper administration. The nurse responsible, RN X, admitted to starting the treatment but did not stay with the resident, and was unaware of the facility's policy regarding nebulizer treatments. Another nurse, RN O, confirmed that staff should remain with residents during such treatments but was initially unaware of the policy as well. Resident #18 experienced a medication error during insulin administration. Nurse A administered Fiasp insulin but did not follow the proper procedure as outlined in the Fiasp Flex Touch instructions. The nurse injected the insulin and held the needle in the skin for only 4 seconds instead of the required 10 seconds. This improper administration could lead to incorrect dosing. The facility's policy/procedure related to inhalation medication, including nebulizer administration, was requested but not provided by the conclusion of the survey.
Failure to Timely Submit PBJ Data and Inadequate Staffing Information Display
Penalty
Summary
The facility failed to ensure timely submission of Payroll-Based Journal (PBJ) data for the second quarter of 2023, leading to staffing concerns being triggered by CMS. The facility's policy mandates that direct care staffing information be reported electronically to CMS no less frequently than quarterly, with specific deadlines for each fiscal quarter. However, the third-party payroll service used by the facility did not submit the required data on time, resulting in excessively low weekend staffing being flagged for the fourth quarter of 2023. This issue was compounded by a change in the third-party payroll service system in January 2023, which may have contributed to the delay. Additionally, observations and interviews revealed that the facility's posted nursing staffing information was not easily readable, which could hinder effective communication and staffing management. The Nursing Home Administrator acknowledged that the placement of the staffing report needed to be reviewed and improved. The Corporate Clinical Director of Operations confirmed that the PBJ policy and procedure were in place and that the corporate payroll department was responsible for submissions. Despite having analysts to review staffing submissions, the facility still received a citation for low weekend staffing.
Failure to Monitor and Justify Antibiotic Use
Penalty
Summary
The facility failed to monitor and justify the administration of an antibiotic for a resident, resulting in the resident receiving an antibiotic without appropriate clinical rationale. The resident, who had bilateral lower limb amputations and a stage IV pressure ulcer, was administered ceftriaxone sodium (Rocephin) intramuscularly for a wound infection over a period of seven days. However, the wound culture results, which were available six days after the antibiotic administration began, did not recommend Rocephin for treatment. The culture identified organisms such as gram-positive cocci, Streptococcus agalactiae, and Methicillin-resistant Staphylococcus aureus (MRSA), and listed eight different antibiotics that could have been used, but Rocephin was not among the recommended options. The facility's policies on 'Surveillance of Infections' and 'Antibiotic Stewardship' were not followed, as the antibiotic therapy was not appropriately justified or modified based on the culture and sensitivity results. The Licensed Practical Nurse (LPN) and Infection Control Preventionist reviewed the resident's medication administration record and wound culture report, confirming that the antibiotic administered was not suitable according to the culture results. This failure to adhere to the facility's policies and the inappropriate use of antibiotics could contribute to antibiotic resistance and compromised resident care.
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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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