Wellbridge Of Clarkston
Inspection history, citations, penalties and survey trends for this long-term care facility in Clarkston, Michigan.
- Location
- 5655 Clarkston Road, Clarkston, Michigan 48348
- CMS Provider Number
- 235726
- Inspections on file
- 26
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Wellbridge Of Clarkston during CMS and state inspections, most recent first.
A resident with recent hip surgery, rib and manubrial fractures, and multiple comorbidities, who required substantial assistance with bed mobility and was care planned for fall risk, fell from an elevated bed during incontinence/ADL care when a CNA rolled the resident away from herself and did not stop care or seek help despite the resident exhibiting unusual jerking movements. The resident was later found to have additional fractures and neurologic complaints, and hospital imaging confirmed new manubrial and rib fractures. The facility’s internal investigation concluded the resident rolled too far and slid off the bed, documented the fall as not preventable, and did not fully address the CNA’s description of the resident’s movements, the elevated bed, or the positioning technique used, and contained inconsistencies regarding staff presence, continence status, and environmental details, leading to a deficiency for failure to ensure safe care and adequate accident prevention.
Surveyors found one narcotic wall storage unit with both the outer and inner doors unsecured, with rubber bands around the inner lock and multiple resident controlled medications stored inside while no staff were present. When an RN arrived, they initially believed the unit was locked, then locked the outer door but were unable to lock the inner door, and the DON confirmed there was no working key for that inner lock. Leadership later acknowledged they were already aware that this specific controlled medication wall unit required lock repair, while other similar units had no reported issues, and could not explain why controlled medications had not been removed from the malfunctioning unit despite this knowledge.
Surveyors found that the facility did not maintain sanitary and safe conditions, including an expired ice machine filter and significant lint and chemical residue in the laundry area, with staff unable to explain or address these deficiencies at the time.
A resident with multiple comorbidities, including Alzheimer's, diabetes, and hypertension, who was on blood thinners and antihypertensive medication, experienced a fall with head injury. Facility staff failed to consistently monitor and document vital signs and neuro checks as required by physician orders and facility policy, and blood pressure readings were not regularly recorded prior to medication administration. Documentation of the incident and subsequent monitoring was incomplete and not properly entered into the EMR.
The facility did not assess, monitor, or document non-pressure skin wounds or growths for two residents, failing to follow professional standards and care plans as required.
A resident with fragile skin and multiple health conditions sustained a skin tear from a wheelchair with a missing armrest cap, exposing a sharp edge. Despite the injury being reported, staff did not thoroughly inspect the wheelchair or identify the hazard until prompted by a surveyor, and the resident continued to use the unsafe wheelchair for several days. The facility failed to conduct a timely and thorough investigation or update the care plan in response to the incident.
Two residents experienced deficiencies in skin and wound care, including lack of documentation and assessment of a cutaneous horn and failure to obtain physician orders or properly date dressings for a forearm wound. Facility policy did not address non-pressure skin conditions, contributing to incomplete care practices.
Surveyors found that the facility did not document the required monthly battery test for the generator, omitting either the specific gravity or cold crank amperage check needed to confirm battery operability. This deficiency was confirmed by the Maintenance Director and Administrator and could impact all occupants during a power outage or emergency.
Facility hallways were found to contain gown and isolation cabinets without wheels, preventing quick removal and potentially obstructing emergency egress. This was confirmed by the Maintenance Director and Administrator during surveyor observation, affecting a portion of the facility's occupants.
A portable fire extinguisher in the kitchen service hallway was found without the required monthly maintenance and inspection tag, indicating a failure to document compliance with NFPA 10 standards. This was confirmed by the Maintenance Director and Administrator during surveyor interviews.
Facility staff failed to maintain the required 36-inch clearance around breaker panels in the maintenance office, with combustibles found in front of the panels. This was confirmed by the Maintenance Director and Administrator during the survey.
Surveyors observed that the oxygen cylinder storage rack in the oxygen storage room on hallway #800 was not properly labeled to indicate whether cylinders were EMPTY or FULL, as required by NFPA 99. This deficiency was confirmed by facility leadership and could affect 16 out of 87 occupants in the event of a fire emergency.
A resident with multiple medical conditions sustained a second-degree burn to the left upper thigh after spilling hot coffee. Nursing staff failed to transcribe and implement the physician's order for wound care, did not document the treatment provided, and did not notify the DON or Administrator of the new injury, resulting in a failure to meet professional standards of nursing practice.
A resident with significant medical history experienced a fall resulting in a head injury and elevated blood pressure. The facility failed to notify the physician of the resident's change in condition, including increased bleeding and cognitive impairment. Nursing staff did not escalate the situation appropriately, and the resident's son had to request a hospital transfer. The facility lacked adequate weekend resources, contributing to the deficiency.
A resident with serious health conditions was admitted to the facility and noted to be on oxygen, but no initial physician order was documented. The facility's policy requires verification of a physician's order for oxygen administration, which was not followed. The resident's oxygen orders were not implemented until three days after admission, despite nursing notes indicating the resident was on oxygen. The DON acknowledged the concern but could not explain the delay.
A resident with severe cognitive impairment and high fall risk experienced two falls within nine days of admission to an LTC facility. Despite being aware of the risk, the facility failed to implement timely, resident-specific interventions, resulting in a hip fracture requiring surgery. Staff interviews revealed inconsistencies in fall prevention strategies, contributing to the deficiency.
The facility failed to ensure call lights were within reach and answered promptly, leading to a deficiency in accommodating residents' needs. Observations revealed call lights were not placed within reach and were not answered timely, with some residents waiting over an hour. Specific instances included a resident with an activated call light for over 40 minutes without response and another with their call light out of reach. Despite claims of average response times, documentation did not reflect this, and staff were observed not addressing call lights promptly.
The facility failed to provide adequate ADL care, including personal hygiene and bathing, for eight residents, leading to complaints of poor hygiene and frustration. Residents reported not receiving scheduled showers or baths, and documentation often did not reflect refusals of care. Staff interviews revealed a lack of oversight in ensuring residents' needs were met.
A facility failed to maintain a medication error rate below five percent, resulting in a 22.22% error rate. Errors included incorrect dosages and failure to administer medications as prescribed, such as administering Docusate Sodium 250 mg instead of 100 mg, and not priming a NovoLog FlexPen before insulin injection. The DON confirmed that insulin pens should be primed and medications should not be marked as given until administered.
A facility employed an unlicensed individual as an RN, who worked multiple shifts before the discrepancy was discovered. The individual, with a background in phlebotomy, used another person's RN license to gain employment. The issue was identified by the facility's President of Clinical Services during a routine license check, leading to an investigation that confirmed the falsification of credentials. The former HR Manager responsible for verifying credentials failed to detect the issue and has since resigned.
The facility failed to maintain resident dignity, as evidenced by staff being disrespectful, arguing, and being rude, making residents feel like they were in a facility rather than a home. Incidents included a resident being told to use an incontinence brief instead of being assisted to the restroom, and another resident being given instructions about bathroom use loudly enough to be overheard from the hallway. The DON acknowledged these actions were inappropriate.
A resident's preferences for morning showers and daytime catheter changes were not honored by the facility, despite being cognitively intact and requiring assistance with ADLs. The facility cited scheduling constraints as the reason for not accommodating the resident's requests, which contradicts the Resident Rights Handbook stating residents have the right to choose schedules consistent with their interests.
A resident with intact cognition and multiple diagnoses, including Parkinson's and anxiety disorder, did not receive showers for several days despite multiple complaints from the resident and family. The facility failed to document or resolve the grievance, as staff were unaware of the complaints, and the grievance process was not followed.
A resident admitted with a lung transplant and idiopathic pulmonary fibrosis did not receive most of their medications, including crucial anticoagulant and antirejection drugs, until two days after admission. The initial nurse failed to input medication orders, and a second nurse also missed transcribing an essential antirejection medication, leading to a delay in administration.
A resident with hemiplegia and hemiparesis was not provided with a prescribed resting hand splint due to an error in the physician's order entry, which lacked a schedule for application. The resident, with intact cognition, was observed without the splint on two occasions and indicated that staff did not offer to apply it. The DON confirmed the order was entered incorrectly, leading to the deficiency in care.
A facility failed to follow physician orders and accurately document catheter care for a resident. The resident's catheter was overdue for a change, but the MAR was marked as completed by an LPN who did not perform the task. The LPN cited the resident's preference for a day shift change as the reason, but failed to document the refusal. The DON was unaware of the issue due to the inaccurate documentation.
A resident who had undergone a lung transplant did not receive timely administration of critical medications, including anticoagulant and antirejection drugs, due to transcription errors by nursing staff. The resident's medication orders were not entered upon admission, leading to a delay in medication administration until two days later, with the antirejection medication tacrolimus not being transcribed at all.
A resident's room contained improperly stored medications, including those belonging to a family member. Despite facility policy requiring regular monitoring, the medications remained in the room over several days. The DON was aware but had not addressed the issue with the family member.
Failure to Safely Position Resident During ADL Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide care in a safe manner to prevent an accident during ADL care, resulting in a resident’s fall from bed and subsequent fractures. The resident was an older adult with recent and significant medical issues, including a displaced intertrochanteric fracture of the right femur requiring surgery, a fracture of the manubrium, multiple right rib fractures, trigeminal neuralgia, Meniere’s disease, and psychosis. A recent MDS showed the resident had intact cognition, used a walker and wheelchair, required substantial/maximal assistance for bed mobility, and was dependent for toileting hygiene. The care plan identified the resident as at risk for falls related to multiple conditions, including recent fractures, and included an intervention to encourage and assist the resident to be positioned in the middle of the bed prior to rolling, as well as a transfer status of one-person assist with a two-wheeled walker and non-ambulatory status. During the night, while a CNA was providing incontinence/ADL care, the resident rolled out of bed and onto the floor. The nurse’s progress note documented that the CNA reported the resident rolled out of bed in the middle of ADL care and was found on the floor on her left side, with a broken left pinky nail and later complaints of left shoulder pain. The CNA’s written witness statement and subsequent interview described that the bed was elevated to a working height, the resident was being turned for care, and the CNA rolled the resident away from herself. The CNA reported that the resident began exhibiting unusual jerking and jolting movements and then fell to the floor. The CNA acknowledged rolling the resident away from her during repositioning and stated she did not stop care to seek additional help when the resident’s movements became unusual, explaining that she believed others were busy and she informed the nurse afterward. The DON later stated that the expectation is to roll residents toward the caregiver or get help, and to stop care and notify the nurse when there is a sudden change in condition. Following the fall, the resident complained of pain in the shoulder, ribs, and hip, and later reported dizziness, new visual changes, and a different type of headache. An NP note documented right upper extremity weakness, edema, limited arm elevation, bruising to the right temple, and ongoing rib pain, with the resident reporting she had hit her head during the fall. The NP ordered transfer to the hospital for CT imaging due to head injury complaints. Hospital CT imaging identified a minimally displaced fracture of the right anterior superior manubrium and fractures of the right 1st and 2nd ribs, and the hospital H&P recorded that the resident stated she rolled out of bed as she was being turned by staff. The facility’s internal investigation concluded that the resident rolled too far and slid off the bed during repositioning, characterized the fall as not preventable, and documented that the bed height was appropriate, but did not address the CNA’s description of sudden jerking/jolting movements, the elevated bed during care, or the technique of rolling the resident away from the caregiver despite the resident’s recent hip fracture and need for substantial assistance with bed mobility. Discrepancies were noted between the investigation documents and the clinical record regarding staff presence, continence status at the time of the incident, and environmental details. The surveyor also identified that the facility did not have a specific written policy on positioning, with corporate clinical staff stating that positioning was considered a basic skill staff should know. The facility’s QA tool for the fall with fracture indicated the fall was deemed not preventable and referenced new interventions, but left sections for staff education and QA committee review incomplete. The investigation and documentation did not reconcile or fully incorporate the CNA’s account of the resident’s unusual movements during care, nor did it analyze whether the resident’s functional limitations and recent right hip fracture affected safe repositioning during ADL care. These actions and omissions, including the manner of positioning and rolling the resident away from the caregiver on an elevated bed, the failure to stop care and seek assistance when the resident’s condition changed, and the incomplete and inconsistent internal investigation, led to the cited deficiency for not ensuring care was provided in a safe manner to prevent accidents.
Failure to Secure Controlled Medications in Narcotic Wall Storage Unit
Penalty
Summary
The deficiency involves failure to ensure controlled medications were securely stored in a locked compartment as required by facility policy and professional standards. During observation of the 800 hall narcotic wall storage unit, surveyors found the outer door not properly secured and able to be opened completely, and the inner door, which also had a locking mechanism, was unlocked. The inner door’s lock had several rubber bands around the locking mechanism and one around the lock and top of the inner door, while multiple resident narcotic medications were stored inside with no staff present in the hallway. When the Administrator arrived and was informed of the unlocked controlled substance wall unit, they attempted to locate the nurse responsible for the medications. Shortly thereafter, a nurse approached the wall unit and stated they thought it was locked. The nurse attempted to engage the outer door lock, which was already in the locked position and therefore unable to close, then used a key to lock the outer door. When questioned about the inner door, the nurse attempted to use the same key but reported it did not work and believed the lock had recently been changed or fixed. The DON then attempted to secure the inner door with the same keys and confirmed there was no working key for that door. The nurse reported last accessing the narcotic wall unit at approximately 9:00 AM. Later, during the exit conference, the DON confirmed there were six controlled medication wall units in the facility and that no issues had been found with the others. A corporate nurse acknowledged prior awareness of the need for repair to that specific wall unit’s lock and that they had been working on having it fixed, and did not provide an explanation when asked why controlled medications had not been removed from that storage area despite knowing it was not locking properly. The facility’s policy states that only authorized licensed nursing and pharmacy personnel have access to controlled medications and that the medication nurse on duty maintains possession of the key to controlled medication storage areas.
Failure to Maintain Sanitary and Safe Environmental Conditions
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During an environmental tour of the kitchen, the ice machine was found to have an expired filter with a 'change by date' that had passed, and the Regional Kitchen Manager was unable to explain why it had not been changed. Additionally, a tour of the laundry room revealed that the area behind multiple dryers had a floor surface covered with dried liquid spillage from cleaning chemicals, and the tops of the dryers were covered with a thick layer of lint. The facility Administrator acknowledged the presence of these unsanitary conditions.
Plan Of Correction
1.) The laundry room, including all machines and the floor behind the machines, was cleaned and dusted, and the ice machine filter was changed. 2.) A one-time audit was completed to ensure that dusting was completed throughout the facility and all ice filters were clean and changed. The housekeeping and maintenance departments were re-educated. 3.) System Change: All water filters will be changed according to manufacturer guidelines. The administrator/designee will complete rounds weekly to ensure the facility, including appliances/machinery, is kept clean. 4.) The administrator/designee will complete weekly rounds for 12 weeks to ensure the facility, including appliances/machinery, is dust free and will also conduct routine rounds to ensure there are no expired water filters. Any non-adherence will result in 1:1 education. All audits will be taken to QA for review. 5.) The administrator is responsible for ongoing compliance.
Failure to Consistently Monitor and Document Vitals and Neuro Checks After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received complete and accurate vital sign monitoring and documentation per physician orders and professional standards of practice. The resident, who had Alzheimer's disease, diabetes, and hypertension, was on two blood thinners (Plavix and Eliquis) and a blood pressure medication (Metoprolol Tartrate). After experiencing a fall in the bathroom and hitting her head, the resident was found with a bump on her head and a skin tear on her right arm. The nurse initiated neuro checks and contacted the provider, but there was no detailed documentation of the head wound in the medical record, and the neuro check documentation was not initially found in the electronic medical record (EMR). Further review revealed that the resident's blood pressure readings were not consistently documented prior to the administration of Metoprolol, as required by physician orders. The Medication Administration Record (MAR) showed the medication was given twice daily, but blood pressure readings were only recorded five times over a two-week period, despite 29 opportunities. This lack of consistent monitoring made it impossible to determine if low blood pressure contributed to the resident's fall. Additionally, the neuro check documentation began 15 minutes after the fall, and vital signs at the time of the fall were not initially available in the EMR. A paper copy of the neuro check sheet with hand-written vitals was later produced, but it had not been previously scanned or included in the EMR. Interviews with nursing staff and the Director of Nursing (DON) confirmed that vital sign monitoring was not consistently performed or documented as required. The DON acknowledged the absence of a detailed skin assessment and the incorrect entry of older vital signs in the change of condition form. The facility's policies required vital sign monitoring prior to medication administration and neurological assessment after falls with suspected head trauma, but these standards were not met in this case.
Plan Of Correction
1.) Resident #64 was assessed and no acute issues were noted. All residents have the potential to be affected. 2.) A one-time review of all guests on hypertensive medications from the last 30 days was completed to ensure hypertensive parameters are being followed. A one-time review of falls within the last 14 days was reviewed to ensure neuro checks were being completed as ordered. 3.) Licensed nurses were re-educated on following parameters on hypertensive medications and on completing neuro checks with unwitnessed falls. System change: The nurse managers will review all new hypertensive medications for parameters if needed and will review all falls to ensure neuro checks were completed for unwitnessed falls. 4.) DON/Designee will review 5 medical records weekly x 12 weeks to ensure that hypertensive medications with parameters are being followed. Any non-adherence will result in 1:1 education. All audits will be taken to the QA committee for review. DON/Designee will review 5 medical records weekly x 12 weeks to ensure that neuro checks were being completed for unwitnessed falls. Any non-adherence will result in 1:1 education. All audits will be taken to the QA committee for review. 5.) The Executive Director is responsible for maintaining compliance with the regulation.
Failure to Assess and Document Non-Pressure Skin Conditions
Penalty
Summary
The facility failed to assess, monitor, and document skin wounds or growths for two residents who were reviewed for non-pressure skin conditions. This deficiency was identified through observation, interview, and record review. The facility did not ensure that care and treatment for these residents were provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, as required by regulations. The lack of assessment, monitoring, and documentation specifically pertained to non-pressure skin conditions for the two residents involved.
Plan Of Correction
1.) Residents #66 & #57 were reassessed, and no acute changes were noted. All residents have the potential to be affected. 2.) A one-time skin sweep was completed to ensure that all impaired skin integrity had treatments or were identified in other parts of the medical record as needed. 3.) Licensed nursing staff were re-educated on skin assessment, documentation, and treatment orders with impaired skin integrity. System change: The nurse managers will review skin assessments and 24-hour summary on the next business day to ensure the MD/provider was notified of impaired skin integrity. 4.) DON/Designee will review 5 medical records weekly x 12 to ensure that residents with impaired skin integrity had documentation and an order for treatment. Any non-adherence will result in 1:1 education. All audits will be reviewed by the QA committee. 5.) DON is responsible for ongoing compliance.
Failure to Investigate and Address Accident Hazard After Resident Injury
Penalty
Summary
A deficiency occurred when a resident with fragile skin and multiple comorbidities, including lumbar vertebra compression, sick sinus syndrome, postural dizziness, cirrhosis, and kidney failure, sustained a skin tear on their right forearm after hitting it on the armrest of their wheelchair. The incident happened while the resident was in the bathroom, and the injury was attributed to a missing plastic cap on the right armrest, which exposed a sharp metal edge. The missing cap was not visible to the resident while seated but was observable to someone inspecting the wheelchair from the front. Despite the resident reporting the injury and the presence of a visible dressing, no one inspected the wheelchair for hazards following the incident. Multiple observations over several days revealed that the resident continued to use the same wheelchair with the exposed sharp edge, and staff, including the assigned LPN and therapy staff, did not identify or address the missing cap. The LPN, who was present at the time of the incident and on subsequent days, reported checking the wheelchair but did not notice the hazard until it was pointed out by the surveyor. The resident's care plan noted the risk of skin impairment and included general interventions, but there were no updates or specific interventions added after the incident. The facility did not initiate a thorough investigation or root cause analysis immediately following the event, and no incident or accident report was completed until the surveyor brought the issue to the attention of facility leadership. Interviews with staff, including the DON and therapy staff, confirmed that a comprehensive inspection of the wheelchair was not performed in relation to the resident's injury. The facility's policy required prompt investigation and documentation of accidents, including a detailed account of the circumstances and contributing factors, but this process was not followed. The deficiency was identified due to the lack of timely and thorough investigation, failure to identify and remove the accident hazard, and inadequate follow-up to prevent further harm.
Plan Of Correction
1.) Resident #61 is no longer in the facility. All residents have the potential to be affected. 2.) A one-time review of residents in-house was completed to ensure that a root cause analysis was completed for any accident/incident that resulted in an injury. A one-time audit of all wheelchairs was completed to ensure no safety issues were identified. If any were found, they were corrected by IDT. 3.) Licensed nursing staff were re-educated on assessing potential cause of injury due to an accident/incident. System change: Nurse Managers will complete documentation on root cause analysis resulting in injury from accident/incident. 4.) Don/Designee will review 5 E-interact change of condition assessments weekly x 12 weeks to ensure that all injuries from an accident/incident are reviewed for root cause analysis. Any non-adherence will result in 1:1 education. All audits will be taken to QA for review. 5.) The Executive Director is responsible for maintaining compliance with the regulation.
Deficiencies in Skin Assessment, Documentation, and Wound Care
Penalty
Summary
A deficiency was identified regarding the lack of proper skin assessment and documentation for a resident with a significant skin abnormality. Upon observation, a resident was found to have a cutaneous horn on the scalp, as well as similar protrusions on the hand and forearm. Despite the presence of this lesion, there was no documentation of the skin protrusion in the resident's admission assessment, progress notes, or by any nursing or medical staff. Interviews with nursing staff and the DON revealed uncertainty about whether the lesion was present at admission, and the attending physician confirmed the presence of a cutaneous horn but stated it was not something he would typically document. Hospital discharge paperwork did note the lesion, but this information was not incorporated into the facility's clinical record or baseline assessment. Another deficiency was noted in the management of a wound for a different resident. The resident was observed with an adhesive foam bandage on the right forearm, which showed signs of drainage and was undated. Review of the clinical record indicated the wound resulted from a fall, but there was no physician order for the dressing or wound care. The dressing was changed by a unit manager, who admitted to not dating the initial dressing due to lack of a marker and was unable to confirm how old the previous dressing was. The DON acknowledged that wound treatments should have a physician order and that all dressings should be dated, but these practices were not followed. Additionally, the facility's policy provided for review addressed only pressure ulcers and did not include guidance for non-pressure skin conditions. This lack of comprehensive policy, combined with the absence of documentation, assessment, and physician orders for wound care, contributed to deficiencies in the facility's skin and wound management practices for both residents.
Failure to Document Required Generator Battery Test
Penalty
Summary
The facility failed to document a required battery test during the monthly inspection of the facility's generator. Specifically, the records did not include documentation of either the specific gravity of the battery fluids or the cold crank amperage for maintenance-free batteries, as required to ensure the operational condition of the generator's battery. This omission was identified during a record review conducted by surveyors. The deficiency was confirmed by both the Facility Maintenance Director and the Administrator during the exit interview and at the time of record review. The lack of proper documentation and testing could affect all 87 occupants in the event of a facility-wide power outage or fire emergency, as the generator's reliability could not be assured according to NFPA standards.
Plan Of Correction
The Maintenance Director has completed the required monthly battery test inspection of the facility's generator on June 2nd. The Maintenance Director/Designee has been educated to ensure that the monthly battery test inspection of the facility's generator is being conducted and recorded to ensure compliance with the regulation. The Maintenance Director/Designee will conduct a routine review of the life safety binder to ensure that monthly battery test inspections of the facility's generator are conducted and recorded. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.
Obstructed Hallway Egress Due to Non-Movable Equipment
Penalty
Summary
During an observation on May 13, 2025, at approximately 12:05 PM, it was found that the facility did not maintain residential hallways free of non-essential or easily movable equipment. Specifically, gown and isolation cabinets located in the #500 hallway were not equipped with wheels, which would allow for quick movement to clear the hallway in case of a fire emergency. This issue was confirmed by both the Facility Maintenance Director and the Administrator during interviews conducted at the time of observation. The deficiency was noted to potentially affect 20 out of 87 occupants in the event of a fire emergency, as the means of egress was not continuously maintained free of all obstructions as required.
Plan Of Correction
The facility's added wheels to the isolation bins, and the hallways are equipped with isolation bins with wheels to aid in the quick movement to clear a hallway during a fire emergency. The Maintenance Director/Designee has been educated to ensure that the hallways are equipped with isolation bins with wheels to aid in the quick movement to clear a hallway during a fire emergency. The Maintenance Director/Designee will conduct routine rounds to ensure that there are wheels on isolation bins to ensure compliance with the regulation. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.
Missing Fire Extinguisher Maintenance Documentation
Penalty
Summary
During an observation on May 13, 2025, at approximately 9:45 AM, it was found that the facility failed to document the required monthly maintenance for a portable fire extinguisher located in the kitchen service hallway. The inspection and maintenance tag, which is necessary to demonstrate compliance with NFPA 10 standards, was missing from the unit. This issue was confirmed by both the Facility Maintenance Director and the Administrator during interviews conducted at the time of observation. The deficiency could potentially affect 16 out of 87 occupants in the event of a fire emergency, as noted in the findings.
Plan Of Correction
The facility added the fire extinguisher inspection tag to document the required monthly maintenance on the portable fire extinguisher located in the kitchen service hallway. The Maintenance Director/Designee has been educated to ensure that fire extinguishers have the fire extinguisher inspection tag to document the required monthly maintenance. The Maintenance Director/Designee will conduct routine rounds to ensure that fire extinguishers have the fire extinguisher inspection tag to document the required monthly maintenance. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.
Inadequate Clearance Around Breaker Panels
Penalty
Summary
During an observation conducted on May 13, 2025, at approximately 9:45 AM, it was found that the facility did not maintain the required minimum clearance of 36 inches around the breaker panels located in the maintenance office. Combustible materials were observed placed in front of these breaker panels. This situation was confirmed by both the Facility Maintenance Director and the Administrator during interviews at the time of observation. The deficiency pertains to the facility's failure to ensure that equipment using gas or gas-related piping complies with NFPA 54 and that electrical wiring and equipment comply with NFPA 70, as required by regulatory standards. The report notes that this practice could affect 16 out of 87 occupants in the event of a fire emergency.
Plan Of Correction
The facility removed the combustible and there is no longer obstructions at the front of the breaker panels. The Maintenance Director/Designee has been educated to ensure that the maintenance office will maintain a minimum of 36 inches of clearance around the breaker panel. The Maintenance Director/Designee will conduct routine rounds to ensure that the maintenance office is maintaining a minimum of 36 inches of clearance around the breaker panel and they are not obstructed. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.
Improper Labeling of Oxygen Cylinder Storage Racks
Penalty
Summary
The facility failed to ensure proper labeling of oxygen cylinder storage racks inside the oxygen storage room located on hallway #800. During an observation, it was found that the storage rack did not have the required warning sign indicating whether the oxygen cylinders were EMPTY or FULL. This labeling is necessary to comply with NFPA 99 standards for the storage of nonflammable gases. The deficiency was confirmed by both the Facility Maintenance Director and the Administrator during the exit interview and at the time of observation. The lack of proper labeling could affect 16 out of 87 occupants in the event of a fire emergency, as noted in the findings. No additional details about specific residents or their medical conditions were provided in the report.
Plan Of Correction
The storage rack inside the oxygen storage room on hallway #800 has the proper warning sign indicating that the oxygen cylinders are full. The Maintenance Director/Designee has been educated to ensure that oxygen storage racks are labeled with the proper warning sign indicating if the oxygen cylinders are either empty or full. The Maintenance Director/Designee will conduct routine rounds to ensure that the oxygen storage racks are labeled with the proper warning sign indicating if the oxygen cylinders are either empty or full. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.
Failure to Transcribe Physician Orders and Notify Administration of New Skin Injury
Penalty
Summary
A deficiency occurred when nursing staff failed to follow professional standards of practice in the care of a resident who sustained a thermal burn to the left upper thigh. The resident, who had diagnoses including urogenital implants and neuromuscular dysfunction of the bladder, required staff assistance with most activities of daily living and had intact cognition. The burn was identified as a second-degree, in-house acquired injury, and was first noted by the resident, who reported it to nursing staff after returning from an eye appointment where they had spilled hot coffee on themselves. Upon assessment, the wound was described and measured, and a treatment plan involving a wound cleanser and silver sulfadiazine was indicated. However, there was no evidence that a physician's order for the silver sulfadiazine was transcribed into the electronic medical record, nor was there documentation of the treatment being applied on the treatment administration record for the date the wound was identified. Additionally, the nurse who first identified the burn did not notify the Director of Nursing or the Administrator about the new injury, nor did they document the application of an abdominal pad or the completion of the identified treatment in the resident's record. The lack of timely transcription and implementation of physician orders, failure to document wound care, and failure to notify administration of a new skin injury resulted in the facility not meeting professional standards of quality for nursing services. These actions and omissions were confirmed through observation, record review, and interviews with facility staff.
Failure to Notify Physician of Change in Condition Post-Fall
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, R901, following a fall. R901, who had a history of significant cardiac disease, lung cancer, COPD, and diabetes, was found on the floor with a head injury and shoulder abrasion. Initial assessments by RN D and RN A revealed discrepancies in the severity of the injuries, with RN A noting a more severe gash on the forehead than initially reported. Despite concerns about the resident's condition, including elevated blood pressure and cognitive impairment, the on-call physician was not adequately informed of these changes. The nursing staff, including RN A, failed to use their judgment to escalate the situation appropriately. RN A, who was unfamiliar with R901, relied on vague reports and did not immediately send the resident to the hospital despite recognizing the severity of the injuries. The on-call provider, who was not familiar with the resident's medical history, was not informed of the resident's deteriorating condition, including increased bleeding and changes in mental status. The Director of Nursing and the Nursing Home Administrator acknowledged that the facility lacked a charge nurse or nurse manager as a resource on weekends, which may have contributed to the inadequate response. The resident's son, upon visiting, expressed concern about the lack of communication and the resident's condition, ultimately requesting the transfer to a hospital where the resident was admitted under trauma surgery service. The facility's failure to notify the physician and adequately assess and respond to the resident's condition led to a deficiency in care.
Failure to Implement Timely Oxygen Orders
Penalty
Summary
The facility failed to adhere to its policy on oxygen administration for a resident, identified as R404, who was admitted with multiple serious health conditions including acute on chronic systolic congestive heart failure, atrial fibrillation, chronic kidney disease, cardiac murmur, cardiac pacemaker, and dyspnea. Upon admission, the resident was noted to be on oxygen at a rate of 1 liter per minute, but there was no initial physician order documented for this oxygen administration. The facility's policy requires verification of a physician's order for oxygen administration, which was not followed in this case. The deficiency was further highlighted by the fact that the resident's oxygen orders were not implemented until three days after admission, despite nursing notes indicating the resident was on varying levels of oxygen during this period. The Director of Nursing, who was not employed at the time of the incident, acknowledged the concern but could not provide an explanation for the delay in implementing the orders. The lack of timely implementation of physician orders for oxygen administration represents a failure to provide safe and appropriate respiratory care for the resident.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement timely resident-specific interventions and provide adequate supervision to prevent falls for a resident identified as R702. R702, who had severe cognitive impairment and was at high risk for falls, experienced two falls within nine days of admission to the facility. The first fall resulted in a transfer to the emergency room, and the second fall led to a right hip fracture requiring surgery. Despite being aware of R702's high fall risk, the facility did not have appropriate interventions in place prior to the falls. R702 was admitted to the facility for a short-term stay following hospitalization for a left hip fracture. The resident's medical history included dementia, osteoarthritis, and osteoporosis. Upon admission, a fall risk assessment indicated a high risk for falls, yet the initial care plan lacked specific fall prevention measures. It was only after the first fall that interventions such as a toileting schedule and settling the resident in bed after dinner were initiated. However, these measures were insufficient, as evidenced by the second fall. Interviews with facility staff, including CNAs, LPNs, and the Director of Nursing, revealed inconsistencies in the implementation of fall prevention strategies. Staff members mentioned various potential interventions, such as frequent rounding, low beds, and floor mats, but these were not consistently applied to R702's care. The facility's failure to provide adequate supervision and timely, resident-specific interventions contributed to the resident's falls and subsequent injury.
Deficiency in Call Light Response and Accessibility
Penalty
Summary
The facility failed to ensure that call lights were within reach and answered promptly for several residents, leading to a deficiency in accommodating the needs and preferences of residents. Observations and interviews revealed that call lights were not placed within reach and were not answered in a timely manner, with some residents waiting over an hour for assistance. This issue was highlighted in multiple complaints reported to the State Agency and was also a concern raised during a resident council meeting. Specific instances included a resident whose call light was activated for over 40 minutes without response, and another resident who was observed with their call light out of reach on multiple occasions. Despite the facility's claim of average response times between 10-12 minutes, the documentation provided did not reflect this, and there was a lack of proper documentation for call light activations. Additionally, staff were observed not addressing activated call lights promptly, further contributing to the deficiency. The facility's procedures for responding to call lights were not effectively implemented, as evidenced by the repeated observations of call lights being out of reach and not being answered promptly. The Director of Nursing acknowledged the issue and noted that staff should ensure call lights are within residents' reach, but this was not consistently practiced. The deficiency was further compounded by the facility's inability to provide accurate call light reports, indicating a lack of proper monitoring and response to residents' needs.
Deficiency in ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) care, including personal hygiene, bathing, facial hair care, and dressing, for eight residents. This deficiency was identified through observations, interviews, and record reviews. Several residents, including those with intact cognition and those with cognitive impairments, reported not receiving showers or baths for extended periods, despite being scheduled for such care. For instance, one resident did not receive any showers or baths for 16 days, and another resident reported only receiving assistance from an occupational therapist for their first shower during their stay. Residents expressed frustration and embarrassment due to poor personal hygiene, with some residents having unshaven facial hair for several days and others wearing the same clothing repeatedly. Interviews with residents and their families revealed complaints about the lack of assistance with changing clothes and grooming. The facility's documentation often did not reflect refusals of care, and there were discrepancies between reported care and documented care in the electronic medical records. Staff interviews indicated that CNAs documented ADL care using electronic medical records, but there was a lack of oversight and monitoring to ensure that residents' needs were met. The Director of Nursing acknowledged the concerns and mentioned that residents were typically scheduled for two showers per week, with additional showers as needed. However, the documentation and resident reports indicated that this schedule was not consistently followed, leading to the identified deficiencies in care.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 22.22% error rate during a medication administration observation. This was observed when six medication errors occurred out of 27 opportunities for error involving three residents. The errors included incorrect dosages and failure to administer medications as prescribed. For instance, a Licensed Practical Nurse (LPN) administered Docusate Sodium 250 mg instead of the prescribed 100 mg to one resident. Another LPN failed to administer the correct dosage of Omega-3 and Vitamin B Complex to a second resident and marked Magnesium as given on the Medication Administration Record (MAR) despite not administering it. Additionally, a third resident received a Multivitamin without minerals, contrary to the physician's order for Multivitamins with minerals. The report also highlighted procedural errors during medication administration. An LPN was observed not priming a NovoLog FlexPen before injecting insulin, contrary to the manufacturer's instructions, which require an airshot to ensure proper dosing. The Director of Nursing (DON) confirmed that insulin pens should be primed before each use and acknowledged that medications should not be marked as given until they are administered. These observations indicate a lack of adherence to medication administration protocols, contributing to the high error rate.
Unlicensed Staff Employed as RN
Penalty
Summary
The facility failed to verify the credentials of an employee, identified as Staff 'M', who was employed as a Registered Nurse (RN) without having the required education, experience, and valid nursing license. This oversight was discovered after a complaint was filed with the State Agency, alleging that the facility allowed Staff 'M' to work 12 shifts before it was found they did not possess a valid RN license. The investigation revealed that Staff 'M' had used the identity of another individual, RN 'O', to obtain employment and had never been a nurse, although they had experience in phlebotomy. The facility's President of Clinical Services, Staff 'L', identified discrepancies in Staff 'M's license and registry information during a routine check. An interview with Staff 'M' confirmed that they had falsified their credentials and had never been a nurse. Staff 'M' admitted to using the knowledge gained from their phlebotomy experience to impersonate a nurse. The facility's investigation included a review of Staff 'M's time-punch reports, which showed they worked multiple shifts as an RN, including three days of orientation. The former HR Manager, Staff 'K', who was responsible for verifying employee credentials, failed to identify the discrepancies in Staff 'M's documentation and has since resigned. The facility conducted a thorough review of all employee files to ensure the accuracy of their credentials and found no further concerns. The investigation concluded that Staff 'M' had used RN 'O's license and was never a registered nurse, although no negative outcomes were reported for patients under their care during the time they worked at the facility.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure treatment in a dignified manner for three residents, resulting in potential feelings of embarrassment. A complaint was received by the State Agency alleging that residents were not being treated with dignity. The facility's policy on Quality of Life-Accommodation of Needs emphasizes maintaining residents' dignity and well-being. However, observations and interviews revealed that some staff were not respectful, argued, and were rude to one another, making residents feel like they were in a facility rather than a home. Specific incidents included a resident expressing dissatisfaction with staff behavior, another resident being told to use an incontinence brief instead of being assisted to the restroom, and a third resident being given instructions about bathroom use loudly enough to be overheard from the hallway. The Director of Nursing acknowledged that it was inappropriate for staff to be overheard giving such instructions and that residents should not be told to use their incontinence briefs. These actions and inactions by the staff led to the deficiency in maintaining resident dignity.
Failure to Honor Resident's Care Preferences
Penalty
Summary
The facility failed to honor a resident's personal preferences for care, specifically regarding shower and catheter change schedules. The resident, who is cognitively intact and requires assistance with activities of daily living, expressed a preference for morning showers instead of the scheduled Tuesday and Friday afternoons. However, the facility did not accommodate this request, citing that the day shift nurse aides were too busy. Additionally, the resident preferred their indwelling urinary catheter to be changed during the day rather than at night, but this preference was also not honored. The Director of Nursing confirmed that the resident's request for morning showers could not be accommodated due to the full schedule of the day shift CNAs. The facility's Resident Rights Handbook states that residents have the right to choose schedules consistent with their interests, which was not upheld in this case.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to promptly follow up and resolve a grievance for a resident, resulting in feelings of frustration. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status score of 15/15, was admitted with diagnoses including Parkinson's, neuropathy, depressive disorder, anxiety disorder, and muscle weakness. The resident and their family reported grievances about not receiving showers or baths for several days, despite multiple complaints to facility leadership. However, the facility did not have any documentation of these grievances. Interviews with facility staff, including the Director of Care Transitions, Director of Nursing (DON), and the Administrator, revealed that the facility had a grievance process in place, which involved documenting grievances and following up within 24 hours. However, the DON and Administrator were not aware of any grievances related to the resident, and the Assistant Director of Nursing, who was reportedly handling grievances, did not document or follow up on the complaints. The facility's Resident Concerns Policy outlined a procedure for addressing grievances, but it appears this process was not followed in this case.
Failure to Transcribe Admission Medications Timely
Penalty
Summary
The facility failed to timely and accurately transcribe physician orders for admission medications for a resident who was admitted with diagnoses including lung transplant status and idiopathic pulmonary fibrosis. Upon admission, the resident's discharge summary from the hospital included a list of medications, such as anticoagulant and antirejection medications, which were crucial for their condition. However, the resident did not receive the majority of their medications until two days after admission, with only a few medications administered on the first day. The Director of Nursing (DON) acknowledged that the nurse responsible for admitting the resident did not input any medication orders, leading to a delay in transcription. Although a second nurse attempted to rectify the issue, they also failed to transcribe the resident's tacrolimus, an essential antirejection medication. This oversight resulted in the resident not receiving their necessary medications in a timely manner, as confirmed by a review of the medication administration record and the medication order summary.
Failure to Apply Prescribed Splint for Resident
Penalty
Summary
The facility failed to ensure that a splint was applied per the physician's order for a resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident, who had intact cognition with a BIMS score of 13, was observed on two separate occasions without the prescribed resting hand splint on their right arm. The splint was noted to be on the dresser, and the resident indicated that staff did not offer to apply it. The physician's order, dated December 22, 2023, required the splint to be donned during nighttime hours for contracture prevention, but there was no schedule or frequency attached to the order. A review of the resident's comprehensive care plan and treatment/medication administration records for May and June 2024 showed no documentation that the splint had been applied as ordered. The Director of Nursing confirmed that the order was entered incorrectly into the record, lacking a schedule, which resulted in the nursing staff not being prompted to apply the splint. This oversight led to the failure in providing the necessary care to maintain or improve the resident's range of motion as per the physician's directive.
Failure to Follow Physician Orders and Document Catheter Care
Penalty
Summary
The facility failed to follow physician orders and ensure accurate documentation for a resident with an indwelling urinary catheter. The resident, who was cognitively intact and required assistance with activities of daily living, reported that their catheter was supposed to be changed monthly. However, it had been a month and four days since the last change. The Medication Administration Record (MAR) indicated that the catheter change was marked as completed by an LPN, despite the procedure not being performed. The LPN admitted to not changing the catheter as the resident preferred the procedure to be done during the day shift rather than the midnight shift. Despite this, the MAR was inaccurately marked as completed. The Director of Nursing confirmed that documentation should only occur after a task is completed and that any resident refusal should be recorded. The oversight in documentation led to the Director of Nursing being unaware that the catheter change had not been performed.
Failure to Administer Critical Medications Timely
Penalty
Summary
The facility failed to timely and accurately transcribe and administer physician-ordered medications, including anticoagulant (warfarin) and antirejection medicine (tacrolimus), for a resident who had undergone a lung transplant. The resident was admitted to the facility with a discharge medication list from the hospital, which included critical medications such as tacrolimus and warfarin. However, upon review of the resident's medication administration record, it was found that the resident did not receive any medication on a specific date except for calcium carbonate, metformin, and acetaminophen. Notably, there was no documentation of the administration of the antirejection medication, tacrolimus, during the resident's stay. The deficiency occurred because the nurse responsible for admitting the resident failed to input any medication orders, leading to a delay in the administration of most medications until two days after admission. A second nurse attempted to rectify the situation by entering the medication orders, but still failed to include the tacrolimus. This oversight was identified during a conversation with the Director of Nursing, who confirmed the transcription errors and the subsequent delay in medication administration.
Improper Medication Storage in Resident's Room
Penalty
Summary
The facility failed to ensure proper storage and inventory of medications in a resident's room, leading to a deficiency. During an observation, several medications were found in clear storage cubes on the over-bed tray table of a resident, identified as R53. These included a bottle of Rolaids, eye drops, two inhalers, and two bottles of medications with unreadable labels. The resident explained that while the inhalers were theirs, the other medications belonged to a family member who would collect them after work. This situation persisted over multiple days, as the same medications were observed in the same location on subsequent visits. The facility's Director of Nursing (DON) was interviewed and acknowledged that the resident refused to allow the removal of the medications from their room. The DON admitted to not having discussed the issue with the resident's family member and was unaware of the specific medications being stored. The facility's policy on medication storage, which includes regular monitoring and quality assurance checks, was not effectively implemented in this case, as evidenced by the continued presence of the medications in the resident's room.
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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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