Villa At Beecher Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Flint, Michigan.
- Location
- G 3201 Beecher Rd, Flint, Michigan 48532
- CMS Provider Number
- 235363
- Inspections on file
- 39
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Villa At Beecher Place during CMS and state inspections, most recent first.
An RN left her assigned floor during the night shift without waiting for relief, leaving 41 residents without licensed nursing coverage for over two hours while only two CNAs remained on the unit. The RN handed medication and narcotic keys to a receptionist instead of another nurse, and a nurse on another floor declined to assume responsibility due to an already heavy census. During the period without an RN, no 6 AM meds, assessments, or treatments were provided, resulting in missed nebulizer treatments for a resident with respiratory needs and missed suctioning and PEG tube pain meds for a resident with cancer-related pain. Review of controlled substance shift inventories showed incomplete documentation and lack of required dual nurse signatures, and staff interviews confirmed that the absence of licensed nursing staff and missed 6 AM med pass occurred.
An RN left a unit with 41 residents for over two hours without licensed nurse coverage, leaving only CNAs and resulting in no nurse being available to administer scheduled early‑morning meds, PRN meds, or treatments, or to respond to potential emergencies. During this period, multiple residents with serious conditions such as COPD, acute respiratory failure, malignant neoplasms, quadriplegia with trach and PEG, DM with CKD, heart failure, and hypertension did not receive ordered nebulizer treatments, suctioning, PEG‑tube meds, insulin, antihypertensives, diuretics, pain meds, antidepressants, and nutritional supplements, and required assessments such as pain checks, BP monitoring, and turning/repositioning were not documented as done. Narcotic shift counts lacked required dual signatures, late entries by the DON were made about two weeks after the incident instead of contemporaneous charting, and requested policies and accurate hospital transfer lists were not provided or did not match the clinical record.
Surveyors found that controlled medication practices on the 4th floor were deficient when a Lorazepam blister pack on one cart showed 5 tablets remaining while the narcotic log documented 7, and the assigned nurse stated she had planned to document administrations later despite policy requiring immediate documentation. On the same unit, narcotic shift counts on one cart had only a single nurse’s signature instead of two, and on the other cart no count was recorded for a morning shift. An RN had left mid‑shift while responsible for multiple residents, handed medication cart keys to a non‑licensed staff member rather than another nurse, and the scheduled early‑morning med pass was not completed.
A resident with aphasia, right‑sided hemiplegia, dementia with agitation, depression, and moderate cognitive impairment had episodes of loud, combative behavior, including kicking a door, shaking a fist at others, and later punching another resident’s arm. After being sent to the hospital twice for behavioral evaluation, hospital staff determined on both occasions that the resident did not meet criteria for medical or psychiatric admission and discharged him back. Facility staff, including the UM and liaison, reported that management had directed that the resident not be accepted back due to perceived danger to residents and staff, and EMS was not allowed to re‑enter the building with the resident. No formal eviction or discharge notice was issued, the Ombudsman was not notified, and required transfer documentation was missing, despite the facility’s own guidelines requiring notice, preparation, and appeal rights. The resident’s family was told he could not return and was asked to remove his belongings, while the resident remained in the hospital pending alternate placement.
Two residents were physically assaulted on separate occasions by the same behaviorally unstable resident, who staff described as easily agitated, delusional, and unpredictable. In one event, a severely cognitively impaired resident was punched in the face multiple times in a dining room, with a CNA also struck while intervening, yet no post‑incident nursing assessment, injury documentation, pain assessment, or psych referral was entered in the victim’s record. In the second event, a cognitively intact resident with PTSD and schizophrenia reported being repeatedly hit in the head, pulled from a chair, and kicked, with subsequent findings of facial redness, oral bleeding, a loosened tooth, and a documented pain score of 10/10, but with limited pain documentation and no immediate psych follow‑up. Despite staff witnessing the altercations and a police report noting the aggressor’s admission to punching the victim, the DON and abuse coordinator deemed the incidents unsubstantiated and not reportable, delayed completion of investigations, and failed to report the allegations as required by facility policy and federal and state law.
The facility failed to promptly investigate, document, and report two separate resident‑to‑resident physical altercations involving the same aggressor and two different victims. In the first event, a cognitively impaired resident seated in a dining room was punched in the face multiple times by another resident, with a CNA also struck while intervening; the DON was notified hours later, no post‑incident assessments or progress notes were documented for the victim, and the investigation summary was not completed for about two months, with no report submitted to state authorities. In the second event, a cognitively intact resident with PTSD and psychiatric diagnoses reported being repeatedly punched and kicked by the same aggressor in a day room, with nursing documentation, a CNA account, and a police report all describing a physical assault and observed facial redness, yet the DON and abuse coordinator deemed the allegation unsubstantiated, delayed the investigation, could not produce staff written statements, and did not report the incident as required by the facility’s abuse policy and federal/state reporting timelines.
Two residents with cognitive impairment and psychiatric diagnoses were involved in a witnessed physical altercation in a dining room, during which one resident struck another in the face multiple times and then attempted to strike additional residents and staff. Despite documented facial bruising and known behavioral issues, there was no timely post‑incident nursing or provider assessment, no documentation of physical or emotional status, no pain assessment, and no prompt behavioral health or social services referrals or evaluations for either resident. The social services director later acknowledged not being aware of the incident at the time and not initiating referrals, and the facility’s behavior management program requirements for residents with harmful behaviors were not followed.
A resident with multiple medical conditions developed a new wound and was started on antibiotics, but the responsible party was not notified as required by facility policy. The wound care nurse confirmed there was no documentation of notification, and the resident's family reported being unaware of the new wound, antibiotic treatment, and a previous fall.
A resident with a history of cellulitis, peripheral vascular disease, and multiple skin wounds had several new wounds documented in the EMR, but the care plan for skin integrity was not updated to reflect these changes. The care plan had not been revised since earlier in the year, despite facility policy requiring updates with changes in condition. Staff confirmed the care plan should have been updated but was missed.
A resident with multiple medical conditions, including bilateral lower extremity amputations, was left in soiled linens for extended periods and experienced delayed responses to call lights. The resident reported harsh treatment by a CNA and described feeling anxious and blamed after voicing concerns. Outside agency visitors confirmed witnessing the resident left on urine-saturated linen and observed staff ignoring call lights while socializing. These actions were inconsistent with facility policies requiring dignity, respect, and prompt grievance resolution.
Multiple residents experienced excessive heat and discomfort due to inoperable air conditioning units in both common areas and individual rooms. Staff and residents reported ongoing issues with high temperatures, and some fans provided as alternatives were dirty or not functioning. Maintenance staff did not consistently monitor room temperatures or maintain a list of affected rooms, and leadership confirmed that repairs and replacements for the cooling systems were delayed, resulting in prolonged discomfort for residents.
Four residents were not protected from verbal and physical abuse during two separate altercations. In one case, a resident with dementia and alcohol abuse history became agitated and engaged in a physical fight with another resident, resulting in injuries to both. In another case, two cognitively impaired roommates had a violent confrontation involving racial slurs and physical assault, leading to serious injuries and hospitalization. The facility did not update care plans or provide education after these incidents, and lacked a formal process for roommate placement or timely intervention.
A resident with bilateral amputations and multiple comorbidities was provided a wheelchair missing a right-side brake, which was not identified or addressed by therapy or facility staff. The resident, who was cognitively intact and able to self-propel, was unable to use public transportation due to the unsafe condition of the wheelchair. Staff interviews revealed a lack of clarity regarding responsibility for wheelchair inspection and maintenance.
The facility was unable to produce a letter of reliability for its natural gas emergency generator during a record review, leaving its backup power supply vulnerable to fuel supply issues. This deficiency was confirmed by the maintenance director.
The facility did not maintain required documentation for monthly testing of emergency battery back-up lights for both 30 seconds and 90 minutes, and a battery back-up emergency light in the generator room was found to be nonfunctional during observation. These issues were confirmed by the maintenance director.
Surveyors identified that the fire alarm system was not properly tested and maintained, with a standing supervisory alarm and trouble alarm present on the main panel, a tamper switch in the riser room not wired to any system, and a pull station near the dining room exit blocked by a display board, all confirmed by the maintenance director.
Surveyors identified multiple deficiencies in the facility's sprinkler system maintenance and testing, including a dirty sprinkler head, overdue testing of several sprinkler components, missing maintenance tools, and overdue system flushes and valve checks. These issues were confirmed through observation, record review, and interview with the maintenance director.
The facility was unable to provide documentation confirming that the mandatory four-year HVAC damper inspection had been completed, as discovered during a record review and confirmed by the maintenance director. This left the operational status of the dampers unverified.
The facility did not provide documentation for required first shift, first quarter fire drills, as confirmed by record review and interview with the maintenance director. This failure means staff may not have participated in or been prepared for mandated fire emergency procedures.
Surveyors observed that double rated fire doors on the 3rd floor did not close when released from magnetic hold open devices, resulting in smoke barriers not meeting the required 1/2-hour fire resistance rating. This deficiency was confirmed by the maintenance director and could impact 40 occupants by allowing smoke, heat, and fire to pass between compartments.
Surveyors found that two power strips were connected together in the social work office, which does not comply with NFPA standards for electrical system safety. This practice was confirmed by the maintenance director and could affect 15 occupants in the event of an electrical-related fire.
Three residents did not receive appropriate wound care and preventive interventions as ordered, including daily PEG tube dressing changes, use of Prafo boots, and proper wound assessment and documentation. Staff failed to follow care plans and physician orders, and did not consistently document wound treatments or apply required preventive measures.
A resident with a history of wandering and elopement risk was able to leave the facility unsupervised after his Wanderguard was removed due to swelling. Despite attempts to replace the device, the resident refused, and no additional safety measures were implemented. The resident exited the facility without triggering alarms and was later brought back inside by a transportation aide. Staff interviews revealed a lack of communication and coordination regarding the resident's safety measures.
A facility failed to document a catheter change and follow up on a positive urinalysis for a resident with a urinary catheter. The resident's catheter tubing and bag were discolored bluish purple, indicating a potential urinary tract infection, which was not initially recognized by staff. Despite a care plan requiring monitoring and documentation, there was no progress note for the catheter change or follow-up on the positive urinalysis.
A resident suffered multiple fractures and a shoulder dislocation after a mechanical lift strap broke during a transfer at an LTC facility. The sling used was defective, and staff failed to inspect it before use. The facility lacked a specific policy for the lifts in use, and the reference manual was incompatible with the equipment. The resident was in severe pain, but no pain relief was administered before hospital transfer.
Two residents in the facility developed or were at risk of worsening pressure ulcers due to inadequate care and documentation. One resident developed an unstageable pressure wound on the foot, with observations showing the foot against the bed's footboard, despite known risks. Another resident had multiple skin impairments, with delayed documentation and treatment not reflecting physician recommendations. The facility's wound care management policy was not followed, leading to deficiencies in care.
A resident with multiple medical conditions experienced neglect when a nurse failed to administer scheduled medications, including narcotics, leading to pain and suffering. The nurse signed out the medications but did not give them to the resident, altering the narcotics log and failing to notify the physician. The incident was discovered during a facility tour, and the nurse subsequently quit.
A resident with chronic pain did not receive scheduled doses of Hydrocodone-Acetaminophen, leading to unrelieved pain. Nurse K failed to administer the medication on time, despite it being signed out, and inaccurately documented the administration times. The DON was unaware of the issue until informed by the surveyor, and Nurse K later quit mid-shift.
The facility failed to provide sufficient staffing, including RN coverage, leading to delayed care for residents. Multiple residents reported long wait times for call light responses and unmet care needs. A resident with asthma and hypertension noted slow call light responses, while another with quadriplegia experienced 30-minute delays. A group meeting revealed concerns about inadequate staffing, particularly during the third shift, affecting medication administration and call light response times. Individual interviews confirmed these issues, with residents reporting wait times exceeding an hour.
The facility's kitchen was found to have multiple sanitation and food safety deficiencies, including dirty and improperly dried food containers, chipped plates, moldy sub buns, and inadequate dish machine sanitizer concentration. Additionally, there were issues with uncovered food in the freezer, cracked cereal containers, and a leaking ice machine drain line, all of which posed potential contamination risks.
The facility failed to follow infection control standards by not effectively collecting, analyzing, and reporting infection data. Incomplete infection surveillance hindered trend identification. Additionally, the facility inadequately monitored Legionella in the water system, failing to re-sample positive locations or test additional rooms. Several residents with respiratory issues were transferred to the hospital, but their rooms were not tested for Legionella. The Medical Director was unaware of the Legionella presence, indicating a lack of communication and testing.
The facility failed to maintain resident dignity and rights, with issues such as threadbare gowns, inadequate linen, and long call light wait times. Residents reported frustration over unavailable snacks, particularly for diabetics, and staff were observed using personal phones during work hours. Specific incidents included a resident found on the floor without proper clothing and another left without pants, highlighting a lack of care and respect.
The facility failed to provide a clean and comfortable environment, with observations of cluttered and unclean rooms, including one with a strong odor of urine and full garbage cans. A resident reported that their bed was often unmade, requiring them to lay on a bare mattress. A CNA indicated linens are changed when residents shower or if visibly dirty, but could not explain why the bed was not made.
The facility failed to update care plans for several residents, resulting in unmet care needs. A resident's care plan did not address impaired hand function or a new toe wound. Another resident lacked hygiene assistance, and a third had improper catheter positioning. Significant weight loss in two residents was not addressed, and a care plan incorrectly included a removed catheter.
The facility failed to provide timely assistance with ADLs for several residents, leading to frustration and embarrassment. A resident with full cognitive abilities reported receiving only one shower in 30 days, despite being scheduled for twice-weekly showers. Another resident with moderate cognitive loss experienced long delays in response to call lights and inadequate assistance with changing briefs. Other residents also faced deficiencies in ADL care, such as unclean nails, missed showers, and being left in bed without assistance.
The facility failed to document a fall and complete neurological monitoring for a resident with a head injury, lacked supervision for an unsafe smoker, and did not update a care plan after a resident was found on the floor. Additionally, unsafe water temperatures were recorded without corrective action.
The facility failed to adhere to pharmaceutical standards, with expired medications and improper storage temperatures found across multiple floors. Refrigerators on the 2nd and 3rd floors exceeded acceptable temperature ranges, and medication carts were left unlocked. Expired medications and supplies were discovered, and the Director of Nursing was informed of these issues.
The facility failed to consistently provide substantial nighttime snacks to residents, including those with diabetes, leading to dissatisfaction and potential health risks. Residents reported that snacks were often unavailable due to others taking multiple items, and there was a long gap between dinner and breakfast. Staff interviews revealed procedural lapses in snack distribution, and a resident with multiple health issues was not consistently offered a nighttime snack, despite documented nutritional needs.
The facility failed to identify, analyze, and review resistance patterns of infectious organisms in their Antibiotic Stewardship Program, affecting all residents. The DON and new IPC Nurse I admitted the absence of monthly summary reports and antibiograms. Incomplete infection surveillance data from June 2023 to May 2024 hindered trend analysis, and there was no monitoring for multi-drug resistant organisms. The facility's policy on Infection Prevention and Control was not effectively implemented.
The facility exhibited numerous maintenance and sanitation deficiencies, including unsecured oxygen tanks, broken furniture, and strong odors of urine in several rooms. Observations revealed issues such as wet floors, unstable tables, and inadequate housekeeping, with dust and debris accumulating in ventilation systems. Essential supplies were missing in common areas, and maintenance problems like unsecured sinks and broken closet doors were prevalent.
The facility failed to accurately assess and document the code status for two residents, leading to potential miscommunication and inappropriate care. One resident disagreed with the Full Code status documented without their consent, while another had conflicting code status information due to an oversight during readmission. The social worker acknowledged these discrepancies and noted the need for updates.
A facility failed to complete and transmit a discharge MDS assessment on time for a resident with chronic conditions, leading to a deficiency. The resident was discharged, but the assessment was not completed until months later and was only transmitted after a significant delay. The MDS Coordinator, new to the role, was unsure why the assessment was not submitted timely, as it was not added to a batch for submission.
A resident with schizophrenia, major depressive disorder, and severe dementia did not receive the required yearly PASARR Level II Screening or exemption certification for three consecutive years. Despite indications of mental illness and medication use, the necessary documentation was not completed. Interviews with staff revealed confusion over responsibilities, and the deficiency was only addressed after being identified.
The facility failed to develop comprehensive care plans for two residents, one with an indwelling catheter and another with a tracheostomy and PEG tube. Observations showed an uncovered catheter bag and improperly managed tracheostomy and feeding equipment. The care plans lacked specific interventions, leading to potential unmet care needs.
The facility failed to prevent and manage pressure ulcers for residents, leading to new and worsening ulcers. A resident developed a new ulcer on the toe due to inconsistent use of heel boots, while another had multiple ulcers with incomplete wound care documentation. A third resident's positioning devices were not consistently used, contributing to worsening pressure injuries.
A resident with multiple medical conditions developed limited movement in his hand due to the facility's failure to implement necessary interventions for range of motion. Despite therapy orders, the interventions expired, and there was no plan to restore or prevent further decline. Staff interviews revealed a lack of a Restorative Nursing program, and the resident reported not receiving exercises or devices to aid his condition.
The facility failed to properly assess and maintain urinary catheters for three residents, leading to unmet care needs and potential infection risks. A resident had an indwelling catheter without proper documentation, another had a catheter lying flat with discolored urine, and a third had a suprapubic catheter with cloudy sediments. Care plans lacked necessary updates and monitoring, and there was a lack of documentation and testing for potential UTIs.
The facility failed to ensure proper nutrition and hydration for three residents, leading to significant weight loss and lack of access to fresh water. One resident was observed without water at the bedside, despite having a care plan for hydration monitoring. Another resident experienced a 6.78% weight loss, with no updates to the care plan or notification to the medical director. A third resident lost 7.41% of their weight, complained about cold food, and had no updates to their nutritional care plan. These deficiencies highlight issues in the facility's adherence to its policies.
Two residents in an LTC facility experienced deficiencies in enteral nutrition management. One resident received tube feeding at an incorrect rate, while another had unlabeled and undated feeding equipment, risking infection. The facility failed to document feeding administration and resident refusals, violating its policies on enteral nutrition care.
A facility failed to maintain proper respiratory care for two residents. One resident's tracheostomy equipment was not readily available or properly maintained, with outdated humidification and reused suction tubing. Another resident's nebulizer was improperly stored with residue left in the medication cup. Facility policies for tracheostomy care and nebulizer therapy were not followed, posing potential risks of infection and respiratory distress.
Unattended Unit Leaves 41 Residents Without RN Coverage and Missed 6 AM Med Pass
Penalty
Summary
The deficiency involves a nurse leaving her assigned unit and 41 residents without licensed nursing coverage, medication administration, or emergency care capability for over two hours during the night shift. According to the facility incident report and interviews, the RN assigned to the 4th floor (Nurse MI) clocked out and left the facility at 4:19 AM while responsible for 41 residents, with only two CNAs remaining on the floor. She did not wait for relief from another licensed nurse, did not provide a proper handoff, and did not notify the CNAs that she was leaving. Prior to leaving, she turned the medication cart and narcotic keys over to the front receptionist, a non-licensed staff member, instead of directly to another licensed nurse as required by facility policy. The report states that the receptionist, believing the keys should be held by licensed staff, took them to the 3rd floor nurse. The 3rd floor nurse, who already had 48 residents, refused to accept responsibility for the additional 41 residents and did not take the keys, stating it would be unsafe to be responsible for a total of 89 residents. No licensed nurse was present on the 4th floor from approximately 4:19 AM until about 6:30 AM, when the 4th floor unit manager arrived after being informed there had been no nurse on the unit for over two hours. During this period, only the two CNAs provided care, and they reported they were busy with resident care and did not realize the nurse had left until the morning nurse arrived. As a result of the absence of a licensed nurse, all 6:00 AM medications, assessments, and treatments for the 41 residents on the 4th floor were not administered or performed. Record review showed that one resident (R6) missed scheduled albuterol nebulizer treatments at midnight and 6:00 AM, and another resident (R5) did not receive scheduled suctioning by mouth at 6:00 AM, as well as scheduled PEG tube medications for cancer pain at 2:00 AM and 6:00 AM. A nurse who came on at 7:00 AM confirmed that 6:00 AM medications, vital signs due for medications, and nebulizer treatments were not given, and that she began the 8:00 AM medication pass upon starting her shift. Narcotic reconciliation records for the 4th floor medication carts showed missing or incomplete shift inventory documentation, including lack of a 7:00 AM shift entry for one cart and only a single nurse signature on multiple dates for the other cart, despite policy requiring two nurse signatures each shift. The facility’s resident rights policy and employee handbook, as cited in the report, specify residents’ rights to be free from neglect and require staff not to leave assigned workstations or leave work early without proper approval and handoff.
Unattended Unit Leads to Missed Early‑Morning Medications, Treatments, and Documentation Failures
Penalty
Summary
The deficiency involves the facility’s failure to ensure continuity of care and timely administration of medications and treatments for all 41 residents on the 4th floor when the only licensed nurse assigned to that unit left the building for over two hours without relief. According to the facility incident report and interviews, the RN assigned to the 4th floor clocked out and left at approximately 4:19 AM, leaving 41 residents with only two CNAs and no licensed nurse to assess, administer medications, or respond to medical needs and emergencies between 4:19 AM and about 6:30 AM. The nurse left the medication keys with the front receptionist instead of a licensed nurse, and the receptionist then attempted to give the keys to the 3rd floor nurse, who refused to assume responsibility for an additional 41 residents. The DON, who was the on‑call manager, did not respond to calls or texts at the time because she was asleep, and no other nurse manager or on‑call nurse responded, leaving the 4th floor without licensed nursing coverage during that period. Record review showed that during this time frame, multiple scheduled medications, PRN medications, and treatments due during the night and early morning were not administered or documented as given for numerous residents with significant medical conditions. One resident with pain, vascular angioplasty, malignant neoplasm of bone, and a pressure ulcer did not receive scheduled 6:00 AM medications including Lasix and omeprazole, and PRN hydrocodone for pain was not assessed or administered. Another resident with type 2 DM, COPD, and chronic pain did not receive scheduled famotidine and hydralazine doses, and PRN pain medication was not assessed. A resident with COPD, heart failure, and acute kidney failure did not receive scheduled ipratropium‑albuterol breathing treatments at midnight and 6:00 AM, and pain assessments and PRN pain medications were not documented. A resident with malignant neoplasm of the mandible, PEG tube, and need for routine suctioning did not receive scheduled suctioning, levothyroxine, gabapentin, ondansetron, or scheduled PEG‑tube pain medications during the night and early morning. Additional residents with acute respiratory failure, quadriplegia with tracheostomy and gastrostomy, chronic pain, diabetes, CKD stage 5, hypertension, heart failure, and other serious diagnoses also missed ordered treatments and medications. One resident missed albuterol nebulizer treatments at midnight and 6:00 AM and was later sent to the hospital for a change in condition on that date. Another resident did not receive scheduled lidocaine patches for knee pain. A quadriplegic resident with trach and PEG did not receive scheduled baclofen, nutritional supplement (Med Pass), tizanidine, or documented turning and repositioning every two hours. A resident with diabetes and CKD stage 5 did not receive scheduled insulin glargine at 6:00 AM. Other residents did not receive scheduled furosemide, omeprazole, sertraline, Ventolin inhaler doses, ipratropium‑albuterol breathing treatments, or ordered blood pressure checks and antihypertensive medication at 6:00 AM. Late entries by the DON were made approximately two weeks later, documenting generic assessments such as “no signs and symptoms of pain or discomfort noted,” without contemporaneous documentation from the date of the incident. The investigation also identified failures in narcotic control documentation and shift‑to‑shift reconciliation. Review of the controlled substance shift inventory for the 4th floor medication carts showed missing entries and lack of required two‑nurse signatures for narcotic counts on the relevant date and surrounding dates. The Unit Manager confirmed that policy requires two nurse signatures each shift to balance narcotics and that if it is not written, it did not happen. The facility’s charting and documentation policy requires that all services provided, progress toward care plan goals, and any changes in condition be documented in the EMR to facilitate communication among the interdisciplinary team, yet multiple services, assessments, and medication administrations during the period without a licensed nurse were not documented as provided. The administrator did not provide requested policies related to medication administration, scheduling, narcotic counts, change‑of‑shift duties, and missed medications at the time of surveyor request, and the list of residents sent to the hospital did not include the resident who was documented as having been sent out for a change in condition on the date in question.
Failure to Reconcile and Secure Controlled Medications on 4th Floor Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate reconciliation and secure handling of controlled medications on the 4th floor medication carts. During a narcotic count on the 4th floor East cart, the Unit Manager identified that a blister pack of Lorazepam 0.5 mg, ordered every 4 hours as needed for anxiety, contained only 5 tablets when the narcotic sign-off sheet documented 7 tablets on hand the previous day. The discrepancy of 2 tablets was confirmed by the Unit Manager, who verified that the written inventory did not match the actual blister pack count. When questioned, the nurse assigned to the resident stated she was planning to document the administrations, and the Unit Manager stated that nurses are required to sign for medications as soon as they are administered. Additional deficiencies were identified in the reconciliation of controlled substances on both the East and West 4th floor medication carts. Review of the West cart’s controlled substance inventory for a specific morning shift showed only one nurse’s signature instead of the required two signatures from the outgoing midnight nurse and incoming day nurse; the nurse who signed confirmed that the midnight nurse had left the building early and did not return, and she did not know with whom she had counted the narcotics. For the East cart, the February controlled substance shift inventory form showed no entry for the morning change of shift on the same date, indicating that no narcotic count was performed at that time. Employee records showed that the midnight nurse left the facility at 4:19 AM while responsible for 41 residents and gave the medication cart keys to a non-licensed staff member instead of directly to another licensed nurse, and the scheduled 6:00 AM medication pass was not completed as required.
Failure to Readmit Hospitalized Resident and Follow Required Transfer/Discharge Procedures
Penalty
Summary
The deficiency involves the facility’s failure to permit the readmission of a long‑term care resident following hospital evaluation and discharge, resulting in the resident remaining in the hospital while alternate placement was sought. The resident had been admitted to the facility with diagnoses including aphasia, right‑sided hemiplegia/hemiparesis after an intracerebral hemorrhage, dementia with agitation and hallucinations, major depression, a need for assistance with personal care, and a history of suicidal behavior. An MDS assessment showed a BIMS score of 11/15, indicating moderate cognitive impairment. The facility’s own transfer/discharge guideline states that residents have the right to remain in the facility and that transfer or discharge must follow specific notice, preparation, and appeal procedures, including notification to the State Long‑Term Care Ombudsman. In the days leading up to the refusal of readmission, the resident exhibited behavioral symptoms. Staff reported that the resident was sometimes combative, grunted loudly, and became frustrated when not understood. On one occasion, the resident kicked a conference room door where management was meeting, shook his fist at staff and other residents, and yelled in the dining area. The NHA stated that the resident could not be threatening other residents and needed to be sent out for a behavior evaluation. A transfer assessment dated for that episode cited increased behaviors, refusal of medication, being physical with staff, and being inconsolable and non‑compliant, although the unit manager later clarified that aside from the fist‑shaking gesture there was no physical contact with staff. The resident was sent to the hospital and returned the same day, and staff reported no new behavioral concerns upon his return. Subsequently, the resident was again in the dining area, became visibly upset, and yelled out a family member’s name. The regional director of clinical operations (RDC) interacted with him, during which he calmed and engaged in coloring and discussion about his communication frustrations. Later that day, while waiting for the elevator, the resident punched another resident in the arm as two residents exited the elevator; the struck resident was assessed and found to have no injuries. The unit manager and RDC reported that the medical director petitioned for a full psychiatric evaluation and the resident was sent to the hospital. However, the hospital social worker stated there was no petition sent from the facility and that on both behavioral presentations the resident was medically and psychiatrically evaluated and did not meet criteria for hospitalization. The hospital discharged the resident back to the facility, but EMS reported they were not permitted to enter the building with him and had to return him to the hospital. Multiple facility staff acknowledged that management had communicated that the resident was not to be accepted back. A nurse reported being told by the unit manager that if the ambulance brought the resident back, staff were not to accept him. The unit manager confirmed that when the hospital called late at night to report they had been told the facility would not accept the resident back, she referred them to upper management and later stated that staff were aware per the NHA that the resident was not to return. The NHA acknowledged that the resident had the right to return but stated that higher‑ups were concerned about safety and that other residents were afraid to come out of their rooms because of the resident’s behaviors. The facility liaison reportedly told the hospital that higher‑ups said the resident could not return because he was a danger to residents and staff. Despite repeated hospital requests, no formal eviction or discharge notice was provided. The resident’s family member reported being told that the resident could not come back and that they needed to collect his belongings, and she stated that his discharge did not align with his long‑term placement goals and that she wanted him to remain near her. The social worker at the facility confirmed that the resident’s discharge plan prior to these events was for him to remain at the facility because his daughter could not care for him at home. She also acknowledged that the resident attempted to readmit from the hospital and was not allowed to return due to behavior, and that she did not notify the Ombudsman. Documentation in the resident’s chart lacked a transfer assessment or progress note for the later hospital transfer, and the RDC acknowledged that no such note had been entered. The hospital social worker documented that the patient was appropriate for discharge back to the facility, but because the facility refused to accept him, he was subsequently admitted to the hospital. This sequence of actions and omissions shows that the facility did not follow its own transfer/discharge guideline and did not permit the resident’s readmission after hospital discharge, thereby failing to ensure a safe and appropriate discharge consistent with the resident’s needs and preferences.
Failure to Protect Residents From Repeated Resident‑to‑Resident Physical Abuse and to Report and Assess Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse and to respond appropriately to resident‑to‑resident altercations involving one resident with a history of agitation and two other residents. In the first incident, a cognitively impaired resident with a BIMS score of 0 was sitting in the first‑floor dining room when another resident, described by staff as easily agitated, swearing, yelling, and unpredictable, came into the area and struck him in the face three times. A CNA witnessed the assault, intervened, and was punched in the face by the aggressor, who then attempted to swing at other residents and staff. Staff reported visible bruising to the victim’s face and overhead paging for help, but there was no documentation in the victim’s medical record of any post‑incident nursing assessment, description of injuries, pain assessment, or physician/NP/PA evaluation, and no psych or therapy referral was documented for either resident following this event. The same aggressor resident, who had mild cognitive impairment (BIMS 11) and was receiving psychotropic medications for dementia‑related psychotic/agitated behaviors and mood stabilization, was involved in a second altercation with another resident who was cognitively intact (BIMS 13) and had diagnoses including PTSD, major depressive disorder, schizophrenia, and anxiety disorder. In this second incident, the cognitively intact resident reported being assaulted multiple times in the head while seated in a day room, with her glasses knocked off and being pulled from her chair and kicked on the floor. A CNA responded to calls for help and found the victim on the floor next to her chair with the aggressor at the edge of his wheelchair, arms in motion as if to strike, and separated them. Nurse’s notes documented that the resident was attacked in the day room, and a police officer later documented slight redness on the victim’s face and that the aggressor admitted punching her. Subsequent nursing notes recorded blood on the victim’s sheets, a slightly loose tooth with old blood around it, and later a pain score of 10/10, but there was no detailed documentation of pain location, quality, or specific pain interventions. Across both incidents, the facility failed to follow its abuse policy requiring prompt, thorough investigation and immediate reporting of abuse allegations. For the first incident, the DON was notified approximately two hours after the event, and the facility did not complete its Verification of Investigation Summary until 60 days later. For the second incident, the DON was notified by phone on the day of the event but did not complete the risk management documentation and investigation until several days later, and the Verification of Investigation Summary was not completed until 31 days after the incident. The abuse coordinator and DON determined both incidents were not reportable and unsubstantiated, despite a staff‑witnessed assault, observed injuries, and a police report documenting the aggressor’s admission to punching the victim. There was no timely psych or behavioral referral documented for the involved residents after either incident, and the social worker reported not being informed of the first incident and learning of the second incident nearly a week later, resulting in no immediate psychosocial follow‑up for the victims. The facility’s own policy required that abuse allegations be reported immediately, but the administrator later acknowledged that both resident‑to‑resident physical altercations should have been reported and taken seriously by the abuse coordinator.
Failure to Timely Investigate and Report Resident‑to‑Resident Physical Altercations
Penalty
Summary
The deficiency involves the facility’s failure to promptly and thoroughly investigate and report two resident‑to‑resident physical altercations, and to document and follow up on the affected residents’ status, as required by facility policy and federal and state law. In the first incident on 12/7/25, one resident (R402) struck another resident (R403) three times in the face in the first‑floor dining room while R403 was seated and unable to fight back. A CNA intervened, was punched in the face by R402, and reported that R402 then attempted to strike other residents and staff. The facility’s risk management report documented that the DON was notified approximately two hours after the incident. Despite staff witnessing the altercation and observing apparent facial bruising on R403, the abuse coordinator determined the event was not reportable, concluding that abuse was not substantiated because R403 was considered unharmed and gave a thumbs‑up when asked if he was okay. R403’s clinical record showed significant cognitive impairment and multiple psychiatric and neurologic diagnoses. His BIMS score was 0/15, indicating severe cognitive impairment, and he had a history of hemiplegia and hemiparesis after an intracranial bleed, major depression, and anxiety disorder, and was receiving paroxetine, divalproex, and Seroquel. Despite this vulnerability and the reported facial bruising, there were no progress note entries, follow‑up assessments, physician or NP evaluations, or psychiatric referrals documented for R403 between 12/8/25 and 12/30/25 related to the altercation. The corporate nurse and DON confirmed that no post‑incident documentation or follow‑up assessments were entered in R403’s record. The facility’s Verification of Investigation Summary for this incident was not completed until 2/5/26, approximately 60 days after the event, and the incident was not reported to the state FRI submission site, contrary to the facility’s abuse policy requiring prompt investigation and immediate reporting, but not later than two hours after an alleged violation is made. The second incident occurred on 12/27/25 and involved another resident (R401) and the same aggressor resident (R402). Nurse’s notes documented that R401 was attacked in the day room by R402, who entered very angry and agitated, struck R401 in the face, and knocked off her glasses. A CNA responded to calls for help and found R401 on the floor next to her chair, with R402 at the edge of his wheelchair over her, arms in motion as if to strike; she separated them and assisted R401 back to her chair, then reported the event to the nurse and 911 was called. The nurse documented that R401 was “scared to death,” and the police report recorded that R401 stated she had been punched in the face, with the officer observing slight redness on the right side of her face. The officer’s report also documented that when asked if he punched R401, R402 answered yes and mimed a punching motion. R401, who had a BIMS score of 13/15 (cognitively intact) and diagnoses including bilateral knee osteoarthritis, PTSD, major depressive disorder, schizophrenia, and anxiety disorder, later told the surveyor she was hit 10–12 times, pulled from her chair, kicked on the floor, bled from her mouth, and was afraid to leave her room afterward. Despite these accounts, the DON and Administrator/Abuse Coordinator concluded that no abuse occurred and deemed the incident not reportable, stating there was no witness that R401 was assaulted. The DON did not begin the facility risk management documentation and investigation until 1/2/26, seven days after the incident, and the Verification of Investigation Summary was not completed until 1/27/26, 31 days after the event. Staff reported that written statements about the incident had been completed and turned over to management, but the DON was unable to locate them when requested by the surveyor. One nurse who documented the incident reported receiving verbal education and a write‑up from management about her documentation and did not answer when asked if she had been asked to change, modify, or delete her note. The facility did not submit either of the two resident‑to‑resident altercation incidents to the state FRI submission site, despite its written abuse policy stating that all abuse allegations, including resident‑to‑resident altercations and injuries of unknown source, must be promptly and thoroughly investigated and reported immediately, but not later than two hours after the alleged violation is made.
Failure to Provide Timely Behavioral Health Follow-Up After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide timely behavioral health assessments and services following a witnessed resident‑to‑resident physical altercation. On 12/7/25, a CNA observed one resident (R402) strike another resident (R403) in the face three times while R403 was seated in the dining room. The CNA intervened, was struck in the face by R402, and reported that after the residents were separated, R402 began swinging at other residents and staff. A facility Risk Management Report documented that R403 was hit in the face three times by another resident while in the dining room and that he was unable to provide a description of the event. R403 had a BIMS score of 0/15, indicating severe cognitive impairment, and diagnoses including hemiplegia/hemiparesis after intracranial bleed, major depression, and anxiety disorder, and was receiving paroxetine, divalproex, and Seroquel. R402 had a BIMS score of 11/15, indicating mild cognitive impairment, and was receiving Seroquel, Depakote, and sertraline for dementia with psychotic/agitated behaviors, mood stabilization, and depression. Despite the altercation and reported visible facial bruising on R403, review of both residents’ clinical records from 12/7/25 through 12/30/25 showed no post‑assault nursing or provider assessments, no documentation of physical findings such as redness, bruising, or discoloration, no assessment of pain, and no progress notes addressing either resident’s physical, social, or emotional status related to the incident. Record review further showed that no timely behavioral health or social services interventions were initiated for either resident after the incident. There was no evidence of psych referrals, evaluations, or therapy referrals for the post‑incident period for either resident, and no social services documentation or visits addressing the altercation for the entire month of December. The Social Services Director acknowledged she did not see R402 after the incident, did not send referrals after the physical altercation, and was unaware of or did not remember being informed of the event involving R403. The facility’s Behavior Management Program policy, which calls for behavior management team involvement for residents with reportable incidents and behaviors harmful to others or interfering with function or care, was not implemented for these residents following the 12/7/25 altercation.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for one resident, resulting in the family not being informed of the development of a new wound and the initiation of antibiotic treatment. The resident, who had a history of cellulitis, peripheral vascular disease, and local skin infection, developed a new wound on the left foot and was started on antibiotics for a wound infection. Review of the electronic medical record showed no documentation that the family was notified of these changes. The wound care nurse, who also served as the unit manager, confirmed during an interview that there was no documentation of notification and attributed the omission to an oversight. Further interview with the resident's daughter revealed that she was not made aware of the new wound on the left foot, the initiation of antibiotics, or a previous wound on the buttocks. The daughter also stated she was not informed about a prior fall. Facility policy requires prompt notification of the resident's representative when there is a significant change in the resident's condition or when treatment is altered, but this was not followed in this case.
Failure to Update Care Plan for Skin Integrity After New Wounds Identified
Penalty
Summary
The facility failed to revise and update the care plan for a resident with multiple wounds, resulting in the care plan not accurately reflecting the resident's current skin integrity status. The resident, who has a history of cellulitis in both lower legs, adult failure to thrive, peripheral vascular disease, and local skin infections, was found to have several wounds identified on different dates, including wounds on the right and left dorsal foot, left proximal lower leg, left lower leg anterior, and left buttocks. Despite these new wounds being documented in the electronic medical record, the resident's skin integrity care plan had not been updated since an earlier date, even though four new wounds had been identified since then. During an interview, the wound care nurse confirmed that the care plan should have been updated to reflect the resident's new wounds and acknowledged that this update was missed. The facility's policy requires care plans to be revised to reflect the current status of the resident and to be reviewed throughout the resident's stay, including upon admission, quarterly, and with changes in condition. However, the care plan for this resident was not revised as required, leading to a discrepancy between the resident's documented condition and the care plan.
Failure to Maintain Resident Dignity and Timely Incontinence Care
Penalty
Summary
A resident with a history of type 2 diabetes, morbid obesity, and bilateral lower extremity amputations was found to have her dignity and respect compromised due to delayed response to call lights and incontinence care. The resident, who was alert and oriented, reported being left in bed soiled with feces for nearly four hours on more than one occasion. She specifically identified a CNA who failed to provide timely assistance with activities of daily living and responded to her requests for help in a harsh and dismissive manner. The resident also described experiencing severe pain and spasms, requiring assistance for toileting, and reported her concerns to various staff members, including nurses and the ombudsman. Interviews with staff and outside agency visitors corroborated the resident's account. The charge nurse recalled the resident reporting being left soiled for prolonged periods and confirmed that the CNA in question was subsequently removed from assignment to the resident's floor. Outside agency representatives witnessed the resident lying on urine-saturated linen, with staff placing a dry pad on top due to a reported linen shortage. These agency visitors also observed delayed call light responses, with the resident left waiting for over 40 minutes while staff were seen socializing at the nurses' station. The resident expressed feeling retaliated against and blamed by staff after voicing her concerns. Facility policy reviews indicated that residents are to be treated with dignity and respect at all times, and that grievances should be addressed promptly without discrimination or reprisal. Despite these policies, the resident's experiences and the observations of outside agencies demonstrated a failure to uphold these standards, resulting in the resident being left in soiled conditions and feeling disrespected and anxious.
Failure to Maintain Safe and Comfortable Environment Due to Inoperable Air Conditioning
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, staff, and the public by not ensuring that air conditioning units were operational throughout the building. Multiple observations revealed that both common areas and individual resident rooms were excessively warm, with temperatures frequently exceeding the facility's stated acceptable range of 72 to 81 degrees Fahrenheit. In several instances, wall units displayed temperatures as high as 90 degrees, and residents and staff consistently reported discomfort due to the heat. Many air conditioning units (PTACs) in resident rooms were not functioning, and the main building cooling system had been out of order for an extended period, reportedly for one to two months. Stand-up fans were used as a temporary measure, but some were not operational or were dirty with built-up debris, further compromising comfort and cleanliness. Residents were directly affected by the high temperatures, with several voicing complaints about the heat and discomfort in their rooms and common areas. Some residents had personal fans, but these were not always effective or clean, and not all residents had access to them. Staff interviews confirmed ongoing issues with the air conditioning, and maintenance staff acknowledged that they had not been consistently monitoring room temperatures or maintaining a list of rooms with non-functioning units. The lack of systematic temperature monitoring and insufficient provision of alternative cooling measures contributed to the ongoing discomfort experienced by residents. Record reviews and interviews with facility leadership confirmed that the main cooling system and many individual room units were awaiting repair or replacement, with 32 new PTAC units ordered but not yet received. Documentation showed that temperature logs were maintained for some common areas, but not for all resident rooms, and that the facility was aware of the temperature issues for an extended period. The State Ombudsman also received complaints from residents about the excessive heat, and observations confirmed that the environment was uncomfortably warm. The facility's failure to maintain operational air conditioning and to ensure a clean and comfortable environment resulted in a deficiency affecting multiple residents.
Failure to Protect Residents from Abuse During Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect four residents from verbal and physical abuse during two separate resident-to-resident altercations. In the first incident, one resident with a history of stroke, dementia, and alcohol abuse returned from a leave of absence visibly intoxicated and became agitated when staff attempted to take his medications. This resident and another resident, who has paraplegia and a history of nerve pain, engaged in a physical altercation in the lobby. Both residents sustained injuries, including a swollen eye, laceration, and redness on the chest and face. Staff interviews revealed that both residents had prior histories of aggressive or inappropriate behaviors, and the care plans for these residents were not updated following the incident. There was no documentation of education or counseling provided to either resident regarding their aggressive behaviors after the altercation. In the second incident, two roommates, both with significant cognitive impairments and complex psychiatric and medical histories, were involved in a physical and verbal altercation in their shared room. One resident, who was severely cognitively impaired and on hospice, was struck multiple times with a shoehorn by his roommate after a verbal exchange that included racial slurs and threats. The injured resident sustained a scalp laceration, a fractured right shoulder, and a fractured right humerus, requiring hospital treatment. Staff interviews and documentation indicated that the residents had ongoing interpersonal issues, but there was no evidence of proactive intervention or reassessment of their compatibility as roommates prior to the incident. The facility lacked a formal policy for roommate placement and relied on informal assessments and staff familiarity with residents. There was no evidence that the interdisciplinary team reviewed or revised care plans or interventions following these altercations, nor was there documentation of timely or adequate staff response to escalating behaviors. The incidents resulted in significant injuries, emergency room visits, and ongoing feelings of vulnerability and fear among the residents involved.
Wheelchair Provided Without Functional Brake
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including bilateral below-the-knee amputations, diabetes, peripheral vascular disease, COPD, dementia, and muscle weakness, was observed using a wheelchair that was missing a right-side brake. The resident, who was cognitively intact and able to self-transfer and operate his wheelchair, reported dissatisfaction with the wheelchair provided by the Therapy department, specifically noting the absence of the right brake. The missing brake prevented the resident from using public transportation, as the bus driver deemed the wheelchair unsafe. The resident was unsure how long the brake had been missing. Interviews with therapy staff revealed uncertainty regarding the status of the wheelchair's repair, with one therapist indicating a work order may have been placed, but the Therapy Manager was not aware of the missing brake until the issue was brought to her attention. The resident's care plan identified an increased risk for falls and included interventions related to wheelchair safety, but there was no clear process in place for inspecting wheelchairs to ensure they were in safe working order. The DON and Administrator confirmed that while the Therapy department provided wheelchairs, they were unsure who was responsible for their inspection and maintenance.
Failure to Provide Letter of Reliability for Emergency Generator Fuel Supply
Penalty
Summary
The facility failed to implement emergency and standby power systems in accordance with regulatory requirements. Specifically, during a record review, it was found that the facility could not produce a letter of reliability for its natural gas generator. This documentation is necessary to demonstrate that the generator's fuel supply is dependable and that the emergency power system will function as required during an emergency. The absence of this letter means the facility cannot verify the reliability of its backup power supply. This deficiency was confirmed during an interview with the maintenance director at the time of the record review. The lack of a documented plan or evidence regarding the reliability of the onsite fuel source for the emergency generator leaves the facility's emergency power system potentially vulnerable in the event of a power loss. No information about specific residents or their conditions was provided in the report.
Failure to Maintain and Test Emergency Lighting
Penalty
Summary
The facility failed to ensure that automatic emergency lighting was provided and maintained in accordance with regulatory requirements. During record review, it was found that the facility could not produce documentation verifying that emergency battery back-up lights were tested monthly for 30 seconds or for 90 minutes, as required. Additionally, observation revealed that the battery back-up emergency light in the generator room did not function when tested. These findings were confirmed through interviews with the maintenance director at the time of record review and observation.
Fire Alarm System Testing and Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure the fire alarm system was properly tested and maintained in accordance with NFPA 70 and NFPA 72 standards. Observations revealed a standing supervisory alarm on the main fire alarm panel for a tamper switch in the main riser room, as well as a standing trouble alarm on the fire alarm system. Additionally, a tamper switch in the riser room was found not wired into anything, and a pull station near the dining room exit door was blocked by a display board, making it not visible. These deficiencies were confirmed through interview with the maintenance director at the time of observation.
Deficient Sprinkler System Maintenance and Testing
Penalty
Summary
The facility failed to maintain and test its automatic sprinkler and standpipe systems in accordance with NFPA 25 standards. During an observation, a dirty sprinkler head was found in the scheduler's office, which could prevent the sprinkler from functioning properly in the event of a fire. Record reviews revealed that several required maintenance and testing tasks were overdue, including testing of horizontal sidewall sprinkler heads, testing of the dry pendant sprinkler in the freezer, and replacement of fire sprinkler system gauges. Additionally, the spare sprinkler head cabinet was missing the proper wrench needed for maintenance. Further review showed that the Pre-Action fire suppression system was overdue for internal and check valve testing, and the Pre-Action fire protection system was past due for a required three-year full flush. These deficiencies were confirmed through interviews with the maintenance director at the time of observation and record review. No information about specific residents or their conditions was provided in the report.
Lack of Documentation for Required HVAC Damper Inspection
Penalty
Summary
The facility failed to provide documentation verifying completion of the required four-year damper inspection for its heating, ventilation, and air conditioning (HVAC) system, as mandated by regulatory standards. During a record review, it was found that the facility could not produce evidence that this inspection had been performed. This deficiency was confirmed through an interview with the maintenance director at the time of the review. The absence of this documentation means the facility could not confirm whether the dampers were in working condition.
Failure to Conduct and Document Required Fire Drills
Penalty
Summary
The facility failed to conduct fire drills as required by regulations 19.7.1.4 through 19.7.1.7. During a record review on May 21, 2025, it was found that the facility could not provide documentation showing that the required first shift, first quarter fire drills had been conducted. This deficiency was confirmed through an interview with the maintenance director at the time of the record review. The lack of documentation indicates that staff may not have participated in or been prepared for fire emergency procedures as mandated.
Failure of Fire Doors to Close Compromises Smoke Barrier Integrity
Penalty
Summary
During an observation on the 3rd floor, it was found that the double rated fire doors did not close when released from their magnetic hold open devices. This failure means that the smoke barriers were not constructed or maintained to provide the required minimum 1/2-hour fire resistance rating, as specified by the applicable codes. The issue was confirmed through an interview with the maintenance director at the time of observation. This deficiency could potentially affect 40 occupants in the event of a fire, as it may allow smoke, heat, and fire to pass from one compartment to another.
Improper Use of Power Strips in Office Area
Penalty
Summary
Surveyors observed that the facility failed to comply with requirements for electrical systems, specifically regarding the use of power strips. During an inspection, it was found that two power strips were connected together in the social work office. This practice is not in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 standards, which govern the maintenance and testing of essential electrical systems and are designed to prevent electrical hazards. The observation was made on May 21, 2025, at approximately 10:50 AM, and the findings were confirmed through an interview with the maintenance director at the time of observation. The report notes that this deficient practice could affect 15 occupants in the event of an electrical-related fire. No additional details about specific residents or their medical conditions were provided in the report.
Failure to Provide and Document Wound Care and Preventive Interventions
Penalty
Summary
The facility failed to provide adequate and appropriate wound care, assessment, monitoring, and documentation for three residents with wounds or at risk for skin breakdown. For one resident with a PEG tube, the dressing was not changed daily as ordered, with the dressing remaining dated several days prior to observation. The care plan did not specify daily dressing changes for the PEG site, and preventive measures for pressure ulcer prevention, such as heel elevation and protective devices, were not implemented as planned. Documentation in the electronic medical record indicated that the resident was dependent on staff for all activities of daily living and had a history of pressure ulcers, yet the required interventions were not consistently provided. Another resident, who was quadriplegic and required total assistance, was observed without prescribed Prafo boots and with feet not elevated, despite an active order and care plan specifying their use while in bed. During wound care, the wound nurse failed to measure wound depth, did not change gloves or perform hand hygiene after taking wound photographs, and did not apply treatment to scabs on the resident's feet. There was no documentation of refusal of the prescribed interventions, and the care plan for skin integrity was not followed. A third resident, recently readmitted after hospitalization, was found without Prafo boots while in bed, contrary to his care plan and wound care orders. The resident reported inconsistent application of the boots by staff. When a facility-acquired stage III pressure ulcer was first discovered, the wound nurse did not document the treatment provided in the nursing progress notes, Treatment Administration Record, or wound summary. The facility's policies required wound treatments to be provided and documented according to physician orders, with complete wound assessments including measurements and characteristics, but these requirements were not met for the residents reviewed.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to maintain the safety of a resident who was at risk for elopement due to wandering behavior. The resident, who had a history of vascular dementia, diabetes, hypertension, and mood disorder, was admitted with a Wanderguard device to prevent elopement. However, the device was removed due to swelling and discomfort, and attempts to replace it were unsuccessful as the resident refused to wear it. Despite being identified as at risk for elopement, no additional safety interventions were implemented to monitor the resident's safety after the removal of the Wanderguard. On the day of the incident, the resident was observed leaving his room and heading towards the elevator with another resident. He was able to exit the facility without triggering any alarms, as the Wanderguard was not in place. A housekeeper noticed the resident attempting to leave and tried to intervene but was unable to prevent him from going outside. The resident was eventually brought back inside by a transportation aide who noticed him sitting outside in his wheelchair. Interviews with staff revealed that there was a lack of communication and coordination regarding the resident's safety measures after the Wanderguard was removed. The nursing staff did not inform management about the removal of the device, and no plan was enacted to ensure the resident's safety through enhanced monitoring. The facility's policy on elopement and wandering residents was not adequately followed, as the resident did not receive the necessary supervision to prevent the incident.
Failure to Document Catheter Change and Follow Up on Positive Urinalysis
Penalty
Summary
The facility failed to document a urinary catheter change and follow up on a positive urinalysis for a resident with a urinary catheter. The resident, who had diagnoses including Multiple Sclerosis, Paraplegia, and Neuromuscular Dysfunction of the Bladder, was observed with a bluish purple tinged Foley catheter tubing and urinary drainage bag. Despite the strong smell of urine in the room, the nursing staff did not assess the color of the urine properly, as the urine could not be seen until the bag was emptied. The resident's care plan included monitoring for potential complications of indwelling catheter use and documenting any catheter changes. However, there was no correlating progress note documenting the catheter change or assessment of the catheter, despite the medication administration record indicating a catheter change. Additionally, a urinalysis from the previous month showed numerous bacteria, but there was no follow-up assessment or documentation from the physician or nurse practitioner regarding the positive result. The facility's infection control nurse and nurse practitioner were unsure about the cause of the bluish purple discoloration of the catheter supplies, initially attributing it to the resident's insurance company. However, a review of the manufacturer's information revealed that the supplies should be clear plastic. The discoloration was later identified as a potential indicator of a urinary tract infection, known as Purple Urine Bag Syndrome, which was not initially recognized or addressed by the facility staff.
Defective Sling Leads to Resident Injury During Transfer
Penalty
Summary
The facility failed to ensure the safety and proper maintenance of a mechanical lift used for transferring residents, resulting in a serious incident involving a resident. The incident occurred when a mechanical lift strap broke during a transfer, causing the resident to fall and sustain multiple fractures and a shoulder dislocation. The resident, who had a history of hemiplegia, diabetes, and chronic obstructive pulmonary disease, was totally dependent on staff for transfers and required the use of a mechanical lift with two staff members assisting. The investigation revealed that the sling used during the transfer was defective, with fraying and holes, which led to the strap breaking and the resident falling. The staff involved in the transfer did not inspect the condition of the sling before use, and one of the CNAs assisting was newly hired and had not received recent training on the use of the mechanical lift. The facility lacked a specific policy for the mechanical lifts in use, and the reference manual used for staff education was not compatible with the lifts available at the facility. Interviews with staff indicated that the resident was in severe pain following the fall, but no pain relief was administered before the resident was sent to the hospital. The facility's audit after the incident found additional damaged slings, highlighting a broader issue with equipment maintenance and staff training. The facility did not have a manufacturer or product manual for the lifts in use, further complicating the staff's ability to ensure safe and proper use of the equipment.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of a pressure wound and implement timely interventions and documentation for two residents. Resident #10 developed an unstageable facility-acquired pressure wound on the left plantar foot. The resident was admitted with conditions including heart failure and diabetes and was at risk for pressure ulcers. Despite this, the resident's care plan was not adequately followed, as evidenced by the resident's foot being observed against the footboard of the bed, which was a known risk factor for pressure injuries. The wound care team noted the wound on 7/24/24, but interventions to prevent the resident from pressing against the footboard were not effectively implemented. Resident #9, who was admitted with severe cognitive impairment and multiple diagnoses, also experienced deficiencies in wound care management. The resident's care plan indicated multiple areas of skin impairment, but there were delays in documentation and treatment implementation. The wound nurse's notes were consistently entered late, and the treatment administration record did not reflect the wound physician's recommendations. This lack of timely and accurate documentation and treatment adherence contributed to the resident's risk of worsening skin conditions. The facility's policy on wound treatment management and documentation was not adhered to, as evidenced by the delayed documentation and failure to update care plans as wounds resolved or worsened. The Director of Nursing acknowledged the issues with documentation and treatment implementation, indicating a systemic problem in the facility's wound care management. These deficiencies highlight the facility's failure to provide adequate care and prevent the development and worsening of pressure ulcers in residents.
Neglect in Medication Administration
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, resulting in a resident having necessary medications, including narcotics, withheld without his knowledge or his physician's approval. The resident, who had a history of multiple medical conditions including stroke, epilepsy, dementia, and chronic pain, was observed in pain and discomfort, rubbing his legs and expressing that his knee and hip were causing him significant pain. Despite being scheduled to receive pain medication, the resident did not receive his medications as ordered, leading to pain and suffering. During a facility tour, a nurse was observed with the medication cart outside the resident's room. The nurse had signed out the narcotic pain medication, Norco, at 8:00 AM and 11:00 AM, but had not administered it to the resident. Instead, the medication was found in a cup in the medication cart, along with other medications that were supposed to be given at 7:00 AM. The nurse altered the narcotics log to change the time of administration and failed to notify the physician about the withheld medications. The Director of Nursing was unaware of the situation until informed by the surveyor. The nurse involved, who was a Nurse Manager, quit in the middle of her shift after the incident. The facility's policies on abuse, neglect, and medication administration were reviewed, highlighting the failure to adhere to procedures designed to prevent neglect and ensure proper medication administration.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as ordered for a resident, resulting in the resident experiencing unrelieved pain, frustration, and helplessness. The resident, who had a history of chronic pain and other medical conditions, was observed rubbing his legs and expressing significant pain. Despite having a physician's order for Hydrocodone-Acetaminophen to be administered every four hours, the resident did not receive his scheduled doses at 8:00 AM and 12:00 PM. During an observation, Nurse K was found with the resident's medications, including Norco, in a medication cup in the cart, which had not been administered. The narcotics log indicated that the medication was signed out, but the resident had not received it. Nurse K eventually administered the medications after being questioned by the surveyor. The Medication Administration Record inaccurately documented the administration times, and the nurse failed to notify the physician about the missed doses. The Director of Nursing was unaware of the situation until informed by the surveyor. Nurse K, who was a Nurse Manager, had picked up an extra shift and later quit in the middle of her shift. The facility's policy on resident rights emphasizes the importance of providing services as per the care plan, which was not adhered to in this case.
Inadequate Staffing and Delayed Care in LTC Facility
Penalty
Summary
The facility failed to provide sufficient staffing levels, including days with less than eight hours of Registered Nurse (RN) coverage, which affected the care of residents. On multiple occasions, the facility did not meet the required RN coverage, specifically on 01/01/24 and 01/15/24, where there were less than eight hours of RN presence. The Nursing Home Administrator was unaware of the reasons for this shortfall, and the scheduler confirmed the lack of adequate RN coverage on these days. Several residents reported issues related to insufficient staffing, such as delayed response times to call lights and unmet care needs. A resident with asthma, obstructive sleep apnea, and hypertension reported slow call light responses and a lack of water provision by aides, suggesting a shortage of staff. Another resident with quadriplegia and pressure ulcers stated that call lights often took 30 minutes to be answered. During a resident group meeting, several residents expressed concerns about inadequate staffing, particularly during the third shift, leading to late medication administration and prolonged call light response times. Individual interviews with residents revealed further issues. One resident with a history of stroke and dementia reported waiting over an hour for call light responses. Another resident with acute respiratory failure and dementia mentioned similar delays. A resident with Parkinson's disease and a tracheostomy indicated waiting times exceeding an hour. Additionally, a resident with heart disease and COPD noted that call light response times varied, with significant delays during early morning hours. These observations highlight the facility's failure to maintain adequate staffing levels to meet the residents' needs effectively.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as observed during an inspection. Dirty plastic food storage containers were stacked and ready for use, and large drink dispensers and a crock pot were stored wet, with lids on, preventing proper air drying. The hot plate dispenser had debris, and many plates were chipped, posing a risk of injury. Additionally, metal tops to steam table food containers were found with food debris, and bowls of ice cream in the walk-in freezer were uncovered, exposing them to potential contamination. Plastic cereal storage containers were cracked, allowing air gaps and the risk of plastic falling into the cereal. In the dry storage area, sub buns were found with mold, and fourteen bags were removed due to visible mold. These packages lacked dates indicating when they were received or their expiration. The facility's policy required food items not in their original delivery box to be dated upon receiving, but this was not followed. The dish machine sanitizer concentration was also inadequate, with test strips showing less than 25 parts per million of chlorine sanitizer after two wash cycles, prompting the use of a three-compartment sink as an alternative. Further inspection revealed a large dried spill and food debris accumulation on the floor of the walk-in cooler, along with a white mold-like substance on the wire racks. The ice machine drain line had a small leak, causing water to accumulate on the floor. These conditions violated the 2017 FDA Food Code, which mandates that physical facilities be cleaned as often as necessary to maintain cleanliness and that plumbing systems be maintained in good repair.
Inadequate Infection Control and Legionella Monitoring
Penalty
Summary
The facility failed to adhere to infection control standards by not collecting, analyzing, and reporting infection surveillance data effectively. The Director of Nursing (DON) and the new Infection Prevention and Control (IPC) Nurse were unable to provide monthly summary reports of infection data, including types of infections, infectious organisms, trends, or resistance patterns. The facility's infection surveillance line listings were incomplete, lacking crucial information such as culture results, signs or symptoms of illness, and specific details about infections. This lack of comprehensive data hindered the facility's ability to identify trends and prevent the spread of infections. Additionally, the facility did not adequately monitor and remediate the presence of Legionella in its water system. Despite positive Legionella results in multiple water samples, the facility did not re-sample the positive locations or test additional resident rooms. The Maintenance Director and Administrator acknowledged the presence of Legionella but did not implement sufficient control measures, such as re-sampling or comprehensive testing. The facility's water management plan was not effectively integrated with the infection prevention and control program, leading to potential risks for residents. Several residents experienced respiratory issues and were transferred to the hospital, but their rooms were not tested for Legionella. The facility relied on urine antigen tests, which were not diagnostic for Legionellosis, and did not perform sputum cultures to detect other Legionella species. The Medical Director was unaware of the Legionella presence in the water system and stated that he would have taken different actions had he been informed. This lack of communication and inadequate testing contributed to the facility's failure to address the potential health risks associated with Legionella.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to maintain the dignity and rights of several residents, as evidenced by multiple observations and interviews. Residents were found wearing threadbare gowns and lacking adequate linen, which compromised their dignity. Additionally, residents reported long wait times for call light responses, with some call lights not being within reach, leading to unmet care needs. The facility's staff was observed using personal phones during work hours, which detracted from their attention to residents and was against facility policy. Residents expressed frustration over the lack of available snacks, particularly for those with diabetes, as snacks were often raided by other residents. This issue was compounded by the long interval between the evening meal and breakfast, leaving residents hungry. The facility's refrigerator lock was broken, and there was no proper record of snack distribution, indicating a lack of oversight in ensuring residents' nutritional needs were met. Specific incidents highlighted further deficiencies, such as a resident found on the floor without proper clothing and another resident left without pants, leading to embarrassment. These incidents, along with the lack of timely response to call lights and inadequate communication about appointments, demonstrate a failure to provide care with dignity and respect. The facility's policies on cell phone use and resident dignity were not adhered to, contributing to the overall deficiency in care.
Facility Fails to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by observations of cluttered and unclean rooms. During a facility tour, one room was found cluttered with garbage on the floor and under the bed, with items piled in chairs and boxes around the room. Another room, listed as empty, had partially empty drink containers on the floor and bedside table. A third room had an unmade bed with a mattress that had a large brown stain and was torn. Additionally, another room was observed to be very dirty, with silverware, papers, and debris on the floor, and sticky dirt smeared on the floor. Resident #33's room was observed to have a strong odor of urine, a full garbage can with old briefs and trash, and a sticky floor. The bathroom garbage was also full with trash and wipes with bowel movement on them. The resident's bed was unmade, with no sheets or blankets present, and the resident reported that the facility often runs out of garbage bags, leading to full garbage cans. The resident also stated that their bed is often not made, requiring them to lay on a bare mattress. Subsequent observations confirmed the bed remained unmade over several days, and a CNA indicated that linens are changed when residents get up for a shower or if the bed is visibly dirty, but could not explain why the bed was not made.
Failure to Update Care Plans Leads to Unmet Needs
Penalty
Summary
The facility failed to review and revise care plans for several residents, leading to potential unmet care needs. For Resident #31, the care plan did not address the impaired function of his left hand, despite the resident expressing a desire for an exercise program. Additionally, the care plan did not include specific interventions for a new dark purple area on the resident's left great toe, which was not previously identified by the wound physician. Resident #46's care plan lacked interventions for personal hygiene, as the resident reported not receiving assistance with shaving and hair washing. The resident was observed to be unkempt and had a strong smell of urine, indicating a lack of adequate care. Similarly, Resident #55's care plan did not address the proper positioning of the urinary catheter, which was observed lying flat on its side, and there was no mention of monitoring urine discoloration. Other residents, such as Resident #12, had outdated smoking assessments and care plans that were not revised to reflect current needs. Resident #30 experienced significant weight loss, but the care plan was not updated to address this issue, and the medical director was not informed. Resident #70 also had significant weight loss, but no interventions were in place to address it. Lastly, Resident #62's care plan incorrectly included a urinary catheter, which had been removed, indicating a failure to update the care plan to reflect the resident's current condition.
Deficiencies in ADL Care and Assistance
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for several residents, leading to feelings of frustration, discouragement, and embarrassment among them. Resident #35, who has full cognitive abilities, reported receiving only one shower in 30 days despite being scheduled for twice-weekly showers. The resident expressed a preference for showers in the shower room rather than in their bathroom due to water spillage issues, which was not documented in their care plan. Additionally, the resident experienced a fall during a transfer attempt, indicating inadequate assistance during transfers. Resident #40, with moderate cognitive loss, reported long delays in response to call lights and inadequate assistance with changing briefs and providing fresh water. Documentation showed only one shower and four bed baths in 30 days, with no care provided during the first week of May. Similarly, Resident #46, who also has moderate cognitive loss, was observed unkempt and with a strong smell of urine in their room. The resident reported not receiving showers or assistance with shaving, and documentation confirmed only two showers in 30 days. Other residents, such as Resident #16, #27, #49, #22, and #101, also experienced deficiencies in ADL care. Resident #16 had long, unclean nails with no documentation of nail care provided. Resident #27 expressed dissatisfaction with the lack of showers and assistance with shaving, while Resident #49 reported missed showers and inadequate documentation of refusals. Residents #22 and #101, both requiring mechanical lifts for transfers, reported being left in bed for extended periods without assistance, despite expressing a desire to get out of bed. These deficiencies highlight a systemic issue in the facility's ability to provide necessary ADL care to its residents.
Deficiencies in Fall Documentation, Smoking Supervision, and Water Temperature Management
Penalty
Summary
The facility failed to correctly document a fall and complete neurological monitoring for a resident who had a fall with a head injury. The resident, who had moderately impaired cognition and required maximal assistance, reported multiple falls, including one where it took hours for staff to respond. Documentation discrepancies were noted, with a fall recorded two days late and neurological checks not completed as required, leaving a significant gap in monitoring. Another resident, identified as an unsafe smoker, was observed smoking without the required safety apron and adequate supervision. Staff members present were unaware of the resident's smoking status and did not have the list of unsafe smokers. The resident had severe cognitive impairment and required supervision while smoking, as per their care plan, which was not adhered to during the observation. Additionally, a resident was found on the floor, soiled and without supervision, after their assigned CNA left for lunch without arranging coverage. The resident, who had severe cognitive impairment and required assistance, was not checked or changed for an extended period. The facility's fall reduction policy was not followed, as the resident's care plan was not updated after the fall. Furthermore, unsafe water temperatures were recorded, with the facility's hot water temperature log showing inconsistencies and a lack of corrective action for temperatures exceeding safe limits.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to store and handle medications in accordance with acceptable pharmaceutical standards of practice across multiple floors. On the 4th floor, the medication storage room's refrigerator was found with a temperature reading of 40 degrees Fahrenheit, and expired medications such as insulin ampules with an expiration date of 4/2024 were discovered. Additionally, the freezer compartment was covered with ice build-up, obscuring its contents. Expired medications and supplies, including hypodermic needles and various supplements, were also found in the storage room and medication cart. The Director of Nursing and floor nurses verified these findings. On the 2nd floor, the medication storage room's refrigerator was at 44 degrees Fahrenheit, exceeding the acceptable range of 31-41 degrees. The temperature log was missing, and expired medications were found, including a Paliperidone ER 6 mg with a discard date of 3/31/24. An unlocked medication cart was left unattended by an agency nurse, posing a risk of unauthorized access. The Director of Nursing was informed of these issues, and expired items were removed from storage. On the 3rd floor, the medication storage room's refrigerator was at 50 degrees Fahrenheit, and the temperature log showed consistent readings above the acceptable limit. Nurses were unsure of the correct temperature range and had not reported the issue. Expired medications were found in the medication cart, and a treatment cart was left unlocked and unattended. The Director of Nursing was notified, and expired items were collected for disposal. The facility's policies on refrigerator temperature logs and medication labeling and storage were requested for review.
Inconsistent Provision of Nighttime Snacks for Residents
Penalty
Summary
The facility failed to consistently offer a substantial evening snack to residents, including those with diabetes, leading to dissatisfaction and potential health risks. During a resident group meeting, it was revealed that snacks were not consistently available, and some residents would take multiple snacks, leaving others without. This issue was particularly concerning for diabetic residents who required a substantial snack to manage their blood sugar levels. The residents expressed frustration over the long period between the evening meal and breakfast, which could be up to 15 hours, and the inadequacy of the snacks provided. Interviews with staff, including the Unit Manager and Dietary Manager, highlighted procedural lapses in snack distribution. The Unit Manager acknowledged issues with the refrigerator lock and the lack of specific snacks for diabetic residents. The Dietary Manager claimed that enough snacks were sent to the floors but admitted that monitoring the distribution was the responsibility of CNAs and nurses. The facility's policy required that diabetic residents be offered a protein source with their nighttime snack, but this was not being consistently implemented. Resident #55, who had multiple health issues including diabetes and severe malnutrition, was not consistently offered a nighttime snack. A review of the resident's records showed that snacks were documented as received only 14 out of 27 days. The resident's care plan identified a potential nutritional problem, and interventions included monitoring for signs of poor hydration and documenting food acceptance. Despite these measures, the resident's nutritional needs were not adequately met, as evidenced by the inconsistent provision of nighttime snacks.
Failure in Antibiotic Stewardship and Infection Control
Penalty
Summary
The facility failed to ensure that resistance patterns of infectious organisms were identified, analyzed, and reviewed in their Antibiotic Stewardship Program, potentially affecting all residents. The Director of Nursing (DON) and the new Infection Prevention and Control (IPC) Nurse I revealed that the facility had not been providing monthly summary reports analyzing antibiotic use, resident infections, and antibiotic culture reports. Additionally, the facility did not utilize an antibiogram to identify resistance patterns. The DON, who had been in the role for one month, acknowledged the absence of written reports and incomplete monthly infection surveillance data, which hindered the facility's ability to analyze data for trends. The facility's infection surveillance from June 2023 to May 2024 lacked comprehensive documentation, with missing line listings for several months and incomplete resident infection reports. There was no documentation of monitoring for multi-drug resistant organisms, and the antibiotics listed did not match with resident infection reports or line lists. The facility's policy on Infection Prevention and Control, which included an antibiotic stewardship program, was not effectively implemented, as evidenced by the lack of adherence to the CDC's Core Elements of Antibiotic Stewardship for Nursing Homes.
Facility Maintenance and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment across multiple floors, as evidenced by numerous observations during a survey. On the 2nd floor, a large wet area was found near air conditioners in the common area, posing a risk to residents who were observed moving through the space. Additionally, a round table in the room was unstable due to a loose pedestal. Several rooms had strong odors of urine, with discarded briefs contributing to the smell. In one instance, an unsecured oxygen tank was found in a resident's room, which the resident did not use or recognize. The tank was partially full and not in a holder, posing a potential hazard. Further observations revealed various maintenance issues, such as broken flooring, unsecured fixtures, and missing or damaged furniture. In room 307, the bathroom floor was broken, and a used bedpan was improperly stored. Other rooms had unsecured sinks, broken closet doors, and wobbly bed footboards. The facility's ventilation system was also neglected, with thick dust and debris covering vents near elevators on the 2nd and 3rd floors. The 2nd floor shower room lacked essential supplies like toilet paper and paper towels, and the clean linen room had dust and lint accumulation. Additional deficiencies included stained window valances, soiled bathroom floors, and improperly stored items in utility rooms. Ceiling tiles in several areas were stained, and an oxygen canister was improperly secured in the 4th floor clean utility room. Maintenance issues extended to broken bed frames, dripping faucets, and biofilm accumulation in bathrooms. A handrail near the 3rd floor clean linen room was detached from the wall, and a resident reported a non-functional over-bed light. Housekeeping was inadequate, with uncleaned spills and food debris in rooms that were supposedly cleaned. A spray bottle in the laundry room lacked proper labeling, and several areas had strong odors of urine, with attempts to mask the smell using air fresheners.
Failure to Accurately Document and Communicate Code Status
Penalty
Summary
The facility failed to ensure that the code status of two residents was accurately assessed, documented, and accessible in their medical records, leading to potential miscommunication and inappropriate care interventions. Resident #35, who was admitted with conditions such as diabetes, COPD, and hypertension, had a Medical Treatment Decision Form indicating Full Code, but it was not signed by the resident. During an interview, the resident expressed disagreement with the Full Code status and stated that he had not been consulted about it. The social worker acknowledged the oversight and mentioned that the resident's code status was due for an update. Resident #55, with diagnoses including multiple sclerosis and severe protein-calorie malnutrition, had conflicting code status information in the medical record. Although the resident had signed a DNR form, the electronic medical record and physician orders incorrectly indicated Full Code. The social worker explained that the error occurred when the resident was readmitted from the hospital, and the nurse failed to reassess the code status. The social worker later provided an updated Medical Treatment Decision Form signed by the resident, indicating a preference for Full Code.
Late Submission of Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment in a timely manner for one resident, resulting in a deficiency. The resident, who was admitted with chronic obstructive pulmonary disease, acute respiratory failure, depression, and hypoxemia, was discharged from the facility on December 4, 2023. However, the discharge MDS assessment was not completed until April 30, 2024, and was not transmitted to the Centers for Medicare and Medicaid Services (CMS) until May 21, 2024. This delay was discovered during a record review on May 21, 2024. An interview with the MDS Coordinator revealed that the assessment was not added to a batch for submission, leading to the oversight. According to the CMS Resident Assessment Instrument (RAI) Version 3.0 Manual, discharge assessments should be completed no later than 14 days after discharge and transmitted no later than 14 days after completion.
Failure to Complete Yearly PASARR Level II Screening
Penalty
Summary
The facility failed to complete the required yearly PASARR Level II Screening and/or exemption criteria certification for a resident diagnosed with schizophrenia, major depressive disorder, and unspecified severe dementia with behavioral disturbances. The resident's medical record showed PASARR forms dated over three consecutive years, each indicating the presence of mental illness and dementia, and the use of antipsychotic or antidepressant medications. Despite these indications, the necessary Level II Evaluation or exemption criteria certification (Form DCH-3878) was not completed for the years 2022, 2023, and 2024. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of the required forms. The Social Worker acknowledged the absence of the necessary documentation and indicated that the doctor was responsible for signing the forms. However, the Social Worker also admitted that the resident should have had the Form-3878 completed, but did not confirm if it had been done in previous years. The Director of Nursing was informed of the deficiency and indicated they would investigate the issue further. The facility later provided the required exemption criteria certification, signed by a Nurse Practitioner, but this was after the deficiency was identified.
Incomplete Care Plans for Residents with Catheter and Tracheostomy
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in incomplete care plans and potential unmet care needs. For one resident, observations revealed an uncovered and full catheter bag, and there was no care plan in place for the catheter. An LPN confirmed the absence of an order, diagnosis, or care plan for the indwelling catheter, and stated that CNA's would only see the task on their point of care charting after a care plan is created. Despite an order for the catheter being entered later, the care plan remained absent, and the resident's minimum data assessment did not indicate the presence of an indwelling catheter. Another resident, who had a tracheostomy and PEG tube, was observed with improperly managed tracheostomy and feeding equipment. The care plan for this resident lacked specific interventions for tracheostomy care and did not include a comprehensive plan for the PEG tube. The resident's medical record indicated a history of Parkinson's disease, acute respiratory failure, and other conditions, and the resident was dependent on staff for self-care. The absence of a comprehensive care plan for the resident's tracheostomy and PEG tube care contributed to the deficiency.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to implement appropriate interventions to prevent and manage pressure ulcers for several residents, leading to the development and worsening of pressure ulcers. Resident #31, who had a history of diabetes, kidney disease, and a right leg amputation, developed a new pressure ulcer on his left great toe. Despite physician orders to ensure the resident's left lower limb was pressure off-loaded, there were inconsistencies in documentation regarding the use of heel boots, and no specific orders were in place for the new ulcer on the toe. Observations revealed that the resident's foot was often against the footboard, and the wound physician was unaware of the new ulcer until it was pointed out during the survey. Resident #55, who had multiple diagnoses including multiple sclerosis and severe malnutrition, was found to have multiple pressure ulcers, some of which were acquired in the facility. The resident's care plan was not updated to reflect the current condition and wounds. There were numerous instances where the nurses did not complete the physician-ordered wound care, as evidenced by the lack of documentation in the Medication Administration Record/Treatment Administration Record (MAR/TAR). This lack of adherence to wound care protocols contributed to the resident's deteriorating skin condition. Resident #101, who was admitted with quadriplegia and existing pressure ulcers, was not consistently provided with positioning devices to aid in pressure ulcer prevention. Despite having pressure-relieving boots, the wedge cushion intended for repositioning was often found unused, either on the window sill or under the bed. The resident reported that the staff did not frequently use the wedge cushion, which was confirmed by observations during the survey. This failure to utilize prescribed positioning devices likely contributed to the worsening of the resident's pressure injuries.
Failure to Address Range of Motion Decline in Resident
Penalty
Summary
The facility failed to identify and implement necessary interventions to address changes in the range of motion (ROM) for a resident, resulting in the resident developing limited movement in four fingers and the thumb on the right hand. The resident, who had a history of diabetes, kidney disease, and other medical conditions, was observed with fingers curled under and expressed that he did not receive any exercise program for his left hand, nor did he have a brace or splint to prevent finger contraction. Despite having orders for physical and occupational therapy, these interventions had expired, and there was no mention of the resident's impaired hand function in the care plans. Interviews with facility staff revealed that there was no Restorative Nursing program in place, although a Functional Maintenance program was mentioned. The Therapy Manager was unaware of the resident's hand contracture and confirmed that the resident had received therapy for a limited period. The resident reported that no exercises were provided by aides or therapists, and there was no plan to restore or prevent further decline in hand function. The facility's policy on Restorative Nursing Programs was not effectively implemented, as evidenced by the lack of services to maintain or improve the resident's abilities.
Deficiencies in Urinary Catheter Care
Penalty
Summary
The facility failed to properly assess and maintain indwelling urinary catheters for three residents, leading to unmet care needs and potential infection risks. Resident #41 had an indwelling catheter with no physician's order, care plan, or CNA tasks documented in the electronic health record (EHR). Observations revealed the catheter bag was uncovered and full of urine, and the resident had a history of urinary tract infections (UTIs). Licensed Practical Nurse (LPN) 'L' was unaware of the specific reasons for the catheter and could not locate necessary documentation in the EHR. Resident #55 was observed with a catheter lying flat in a basin, preventing proper urine flow, and the urine was discolored. The resident had no water at the bedside and expressed concern about not receiving water. The Director of Nursing acknowledged the improper positioning of the catheter. The resident's care plan did not include instructions to prevent the catheter from lying flat or to monitor urine discoloration, and there was no documentation of catheter monitoring until a later date. Resident #30 had a suprapubic catheter with cloudy sediments in the tubing, and the drainage bag was not secured in a dignity bag. The resident could not recall the frequency of catheter changes, and there were no recent updates in the care plan or progress notes regarding the catheter's condition. Additionally, no laboratory tests were ordered to check for potential UTIs, and the Director of Nursing did not provide requested records related to recent urinary or blood tests.
Deficiencies in Nutrition and Hydration Monitoring
Penalty
Summary
The facility failed to ensure proper nutrition and hydration for three residents, leading to significant weight loss and lack of access to fresh water. Resident #55, who had multiple health issues including severe protein-calorie malnutrition and pressure ulcers, was observed without water at the bedside on multiple occasions. Despite having a care plan that included monitoring for hydration issues, the resident expressed concern about not receiving water, and the Director of Nursing confirmed that routine water passes were not being conducted as required by facility policy. Resident #30 experienced a 6.78% weight loss over a month, dropping from 118 lbs to 110 lbs. Despite being cognitively intact and aware of his weight loss, which he attributed to a recent infection, there was no evidence that the medical director was informed of this significant change. The care plan for Resident #30 included reporting significant weight changes, but no updates or revisions were made, and the regional dietician was not notified to assess the situation. Resident #70 also experienced a significant weight loss of 7.41% in less than four weeks, dropping from 281 lbs to 270 lbs. The resident complained about the food being served cold, which may have contributed to the weight loss. Despite the facility's policy to monitor significant weight changes, no updates were made to the nutritional care plan, and the regional dietician was not referred to assess the resident's condition. This lack of action and communication highlights deficiencies in the facility's adherence to its own policies regarding nutrition and hydration monitoring.
Deficiencies in Enteral Nutrition Management
Penalty
Summary
The facility failed to ensure proper administration and management of enteral nutrition for two residents, leading to deficiencies in care. Resident #46, who had a history of stroke, dysphagia, and other medical conditions, was observed receiving enteral feeding at an incorrect rate of 85 ml/hr instead of the ordered 70 ml/hr. This discrepancy was confirmed by the unit manager and nurse, who noted that the medication administration record was not documented as required. The registered dietitian was unaware of the incorrect administration rate, indicating a lack of communication and oversight in the facility's processes. Resident #62, who had Parkinson's disease, a tracheostomy, and a PEG tube, was found with unlabeled and undated enteral feeding equipment, which could lead to infection. The resident's room contained a dirty feeding pump and improperly stored supplies, such as an open suction device and undated syringes. The Director of Nursing confirmed that the equipment should have been dated and replaced daily, and there was no documentation of the resident's refusal of tube feeding or the amount administered, highlighting a failure in record-keeping and adherence to facility policy. The facility's policies on enteral tube medication administration and care and treatment of feeding tubes were not followed, resulting in improper care for both residents. The lack of documentation and adherence to prescribed feeding rates and equipment management standards contributed to the deficiencies observed by the surveyors. These findings indicate a need for improved communication, documentation, and compliance with established care protocols to ensure resident safety and proper nutrition management.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to ensure that emergency tracheostomy equipment was readily available and properly maintained for a resident with a tracheostomy. During an observation, it was noted that the resident's tracheostomy tube and dressing were not properly in place, and the equipment cart lacked a readily accessible outer cannula for emergency use. The water for humidification on the oxygen machine was outdated, and the tracheostomy suction tubing was reused without proper dating. The Director of Nursing (DON) and a nurse were unable to locate the necessary emergency equipment initially, which was later found behind the equipment cart. Another deficiency was observed in the storage and maintenance of nebulizer equipment for a resident with respiratory conditions. The nebulizer was found on the bedside table without a barrier and with visible residue in the medication cup. The resident confirmed that staff often left the nebulizer in this manner. The nurse responsible for the resident acknowledged that nebulizers should be rinsed, dried, and stored properly, but this was not done in this instance. The facility's policies for tracheostomy care and nebulizer therapy were not followed, leading to potential risks of infection and respiratory distress for the residents involved. The tracheostomy care policy required sterile techniques and timely replacement of equipment, while the nebulizer therapy policy outlined proper disassembly, rinsing, and storage procedures, which were not adhered to in these cases.
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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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