Wellbridge Of Rochester Hills
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochester Hills, Michigan.
- Location
- 252 Meadowfield Drive, Rochester Hills, Michigan 48307
- CMS Provider Number
- 235716
- Inspections on file
- 28
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Wellbridge Of Rochester Hills during CMS and state inspections, most recent first.
A resident dependent on two-person assist for bed mobility fell from bed during care when one CNA stepped away, leaving the resident on their side, resulting in a fall and reported pain. In a separate incident, another resident with cognitive impairment and exit-seeking behavior eloped from the facility after staff failed to respond to a wander guard alarm, allowing the resident to leave unsupervised with a visitor. Both deficiencies were due to lapses in supervision and failure to follow safety protocols.
A resident with severe cognitive impairment and complex medical needs did not receive full showers as requested by her legal decision maker, who had clearly communicated that bed baths were not to be substituted. Despite these instructions, the resident received a bed bath instead of a scheduled shower, and the care plan did not specify the requirement for showers only, resulting in care not aligned with the expressed preferences.
A resident with diabetes experienced a prolonged delay in receiving insulin after reporting a high blood sugar level. Despite repeated requests and elevated glucose readings, the LPN and supervisor waited several hours for a provider response before administering additional insulin, contrary to facility protocols and expectations for timely intervention.
The facility did not adequately supervise or implement individualized fall prevention interventions for two residents with severe cognitive impairment and high fall risk, resulting in repeated falls, injury, and hospitalization. Required safety devices were missing from a resident's wheelchair, and a hot liquid spill incident involving another resident was not investigated or documented. Staff relied on generic interventions for all new admissions, and the facility's accident policy was outdated and incomplete.
A resident with severe cognitive impairment was subjected to verbal and physical abuse by a CNA, who was caught on camera hitting the resident's hand and calling them 'Grumpy.' The incident was reported after a family member placed a camera in the room due to suspicions of abuse. The facility's Administrator confirmed viewing the footage and reeducating the CNA on communication and abuse policies.
The facility failed to ensure safe transfer practices, resulting in multiple resident injuries. One resident fell during a toilet transfer, fracturing their tibia, while another experienced repeated Hoyer lift incidents leading to hospital visits. Additionally, a cognitively impaired resident was improperly transported, causing leg pain. The facility's inadequate investigations and lack of proper transfer techniques contributed to these deficiencies.
A long-term care facility failed to ensure proper medication administration, resulting in errors for three residents. A nurse mistakenly gave Xanax to a resident without an order for it after preparing medications for two residents at once. The facility lacked complete documentation for the incidents, and the Director of Nursing confirmed awareness of the errors. The facility's policy on medication-related problems was not followed, leading to these deficiencies.
Two residents in the facility experienced untreated skin conditions due to a lack of proper assessment and documentation. One resident had visible venous ulcers on the feet, with no treatment provided despite physician orders. Another resident reported persistent itching and irritation, requesting Nystatin powder, but received no care. The DON and nursing staff failed to follow skin management policies, resulting in untreated conditions.
The facility failed to secure controlled substances in the 400-Hall due to a broken lock on the medication box, affecting all residents with prescribed controlled substances. A discrepancy in the count of Klonopin was noted, and staff interviews revealed awareness of the issue, but medications were not moved to a secure box. The facility's policy requires double-locked storage for controlled substances.
A resident's clonazepam medication count was found to be incorrect, with two tablets unaccounted for, indicating a failure to prevent misappropriation. The discrepancy was discovered during routine medication counts by LPNs and an RN, but the facility's investigation was inconclusive. The resident had a history of anxiety, dementia, and bipolar disorder.
A resident experienced multiple falls and made an allegation of abuse, resulting in a wrist fracture that was not identified and treated in a timely manner. Despite complaints of pain and visible swelling, the facility did not seek diagnostic tests until weeks later, leading to delayed treatment.
The facility failed to ensure a physician or physician extender evaluated and assessed pressure ulcers for a resident admitted with a right femur fracture and hypertension. Despite initial documentation of red, slow-to-blanch, boggy heels and a red, blanching sacrum and coccyx, there was no documentation of a Deep Tissue Injury (DTI) or orders for treatments until 10 days later. Interviews revealed that medical professionals relied on nursing staff to notify them of wound issues, contrary to the facility's policy on physician services.
Failure to Prevent Resident Fall and Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident, who was dependent for bed mobility and required a two-person assist, fell from their bed during routine care. The incident happened while two CNAs were providing in-bed care after the resident had a bowel movement. One CNA stepped away from the bedside to retrieve gloves, leaving the resident positioned on their side facing the door. During this moment, the resident rolled off the bed and was guided to the floor by staff. The resident, who had cognitive impairment, end-stage renal disease, and an above-knee amputation, reported pain in the head and shoulder and was sent to the hospital for evaluation due to being on blood thinners. The root cause was identified as a failure to maintain safe bed mobility during care, specifically not ensuring the resident was safely positioned before a staff member left the bedside. Another deficiency was identified when a resident with moderate cognitive impairment and a history of exit-seeking behavior eloped from the facility without staff knowledge. The resident was able to leave the premises with a visitor, who pushed the resident in a wheelchair out the front door. Although the resident's wander guard security alert activated the door alarm, staff did not respond in a timely manner. Witness statements revealed that staff assumed the resident was with a family member and turned off the alarm without verifying the resident's whereabouts. The resident was later found outside the facility at a nearby apartment complex by police and emergency services, unharmed. In both cases, the deficiencies were directly related to lapses in supervision and failure to follow established safety protocols. In the first incident, staff did not maintain appropriate supervision and positioning during care for a dependent resident. In the second incident, staff failed to respond appropriately to a wander guard alarm and did not follow the facility's elopement policy, resulting in a resident leaving the facility unsupervised.
Failure to Honor Resident's Bathing Preferences as Directed by Legal Decision Maker
Penalty
Summary
The facility failed to provide care in accordance with the expressed preferences of a resident's legal decision maker regarding bathing routines. The legal decision maker had clearly communicated, both verbally and in writing, that the resident was to receive full showers at least twice a week and that bed baths were not to be substituted for showers under any circumstances. Despite these instructions, documentation and interviews revealed that the resident received a bed bath instead of a scheduled shower, and there was no evidence that a shower was provided on the next scheduled day. The resident's care plan did not specify the requirement for full showers only, and the CNA documentation did not reflect that showers were consistently provided as requested. The resident in question had a history of End Stage Renal Disease and Parkinson's Disease, with severely impaired cognition, and was dependent on staff for all bathing activities. The resident was unable to clearly communicate her preferences regarding showers due to a language barrier and cognitive impairment. The legal decision maker had offered to assist with communication if the resident appeared to refuse showers, but staff did not consistently contact the family as requested. Records showed that the last documented shower occurred several days prior to the incident, and subsequent documentation indicated a refusal but did not show that the family was contacted or that further attempts were made to provide a shower as per the care plan. The facility's documentation practices and care planning failed to reflect the specific bathing preferences, leading to the resident not receiving care in accordance with the legal decision maker's wishes.
Delayed Insulin Administration for High Blood Sugar
Penalty
Summary
A resident with type 2 diabetes, who was admitted to the facility and had intact cognition, experienced a significant delay in receiving appropriate treatment for a high blood sugar episode. On the evening in question, the resident's blood sugar was measured at 420 mg/dl at 9:00 PM. The resident requested insulin, but the nurse on duty stated she could not administer additional insulin without a physician's order. The nurse attempted to contact the on-call health care provider but did not receive a response for several hours. During this period, the resident continued to experience elevated blood sugar levels, with subsequent readings remaining high. The nurse and supervisor informed the resident that they were waiting for a response from the provider and could not administer more insulin due to the lack of specific orders and the risk of hypoglycemia. The resident did not receive the necessary insulin to address the high blood sugar until approximately 2:00 AM, about five hours after the initial report of the elevated level. Facility records and interviews confirmed that the process for escalating care in the event of a delayed provider response was not effectively followed. Both the DON and another RN indicated that a timely response from a provider should occur within 30 minutes to an hour, and that further steps could have been taken to contact another provider or escalate the situation. Facility policy also required timely provider response and escalation if needed, but these protocols were not adhered to, resulting in a prolonged period before the resident received appropriate treatment.
Failure to Prevent Accidents and Implement Resident-Specific Fall Interventions
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision or implement appropriate interventions to prevent accidents for residents at high risk for falls. One resident with severe cognitive impairment and a history of falls was admitted following a hospital stay for a fall-related injury. Despite being identified as high risk for falls, this resident was only provided with generic fall prevention interventions upon admission, which did not address their specific needs or cognitive limitations. The care plan did not include individualized interventions, and the facility did not incorporate information from the hospital indicating the need for a 24-hour sitter. The resident experienced multiple falls in common areas, including the dining room, resulting in a hip fracture and head injury. Family members reported a lack of staff supervision in the dining room, and staff interviews confirmed that only standard interventions were implemented for new admissions, regardless of risk level. Another resident with significant cognitive impairment and a high risk for falls was observed without required safety devices on their wheelchair, such as anti-tip bars and dycem, despite these being listed as care plan interventions. The resident's call light was also found to be inaccessible due to a broken clip. Staff interviews revealed a lack of knowledge about how to access or implement care plan interventions, and the regional nurse consultant confirmed that the required safety devices were not in place. Observations over multiple shifts showed that the resident remained without these interventions, and staff were unaware of the missing equipment until it was pointed out by surveyors. Additionally, the facility failed to investigate an incident in which a resident with cognitive deficits spilled hot coffee on themselves in the dining room. This event was witnessed by a family member and a staff member, but the Director of Nursing was unaware of the incident and no investigation or documentation was found. The facility's policy on accidents and incidents was outdated and did not address the process for fall risk assessment, implementation of resident-specific interventions, or monitoring of interventions. Interviews with unit managers and the DON confirmed that only generic interventions were implemented upon admission, with resident-specific interventions added only after an incident occurred.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident, identified as R402, from mental and physical abuse by a Certified Nursing Assistant (CNA B). The incident was reported to the State Agency following a complaint submitted on 11/27/24. The complaint alleged that CNA B had verbally and physically abused R402 by hitting the resident on the hand and calling them 'Grumpy' multiple times. The family member of R402 had placed a camera in the room due to suspicions of abuse, which captured the incident. The video footage showed CNA B entering R402's room, addressing them as 'Grumpy,' and making an intimidating gesture towards the resident, who was observed pulling away from the CNA. R402 was admitted to the facility with a diagnosis of dementia, major depressive disorder, and anxiety disorder, and was receiving hospice services. The resident's Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of three, signifying severe cognitive impairment. During an interview, the facility's Administrator acknowledged viewing the video footage and confirmed that CNA B was reeducated on communication, company policy for abuse, and quality of care. However, the report does not provide additional information on further actions taken by the facility by the exit of the survey.
Deficiencies in Resident Transfer and Supervision
Penalty
Summary
The facility failed to ensure safe transfer practices for residents, leading to multiple accidents and injuries. One resident, who required maximum assistance for transfers, fell during a toilet transfer when their knee buckled, resulting in a tibia fracture that required surgery. The LPN assisting the resident did not use a gait belt, and the facility's investigation into the incident was inadequate, failing to identify the proper transfer technique or the necessity of using a gait belt. Another resident experienced multiple incidents involving a Hoyer lift, resulting in injuries that required hospital visits. The facility did not conduct thorough investigations into these incidents, and there was a lack of documentation regarding the staff involved and the specific circumstances of the accidents. The facility also failed to ensure that the appropriate Hoyer lift was used for the resident's weight, contributing to the accidents. Additionally, a resident with severe cognitive impairment was improperly transported in a reclining wheeled chair, causing leg pain and distress. The facility's staff did not follow proper procedures for moving the resident, and the incident was observed by the resident's family via Facetime, leading to a police report and emergency department visit. The facility's failure to provide adequate supervision and safe transfer techniques resulted in repeated falls and injuries for another resident with a history of falls and poor cognition.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that nursing staff correctly administered physician-ordered medications to residents, resulting in medication errors for three residents. On one occasion, a nurse mistakenly gave a resident medication intended for another resident, specifically administering Xanax to a resident who did not have an order for it. This error occurred after the nurse had worked a long shift and was preparing medications for two residents simultaneously. The incident was not documented in the resident's clinical record, and the resident was not notified of the error. Additionally, the facility did not provide Incident and Accident reports for all involved residents, specifically lacking documentation for one resident. The Director of Nursing confirmed awareness of the medication errors, which included administering an incorrect medication and dose to another resident on a separate occasion. The facility's policy on medication-related problems emphasizes the importance of following clinical guidelines to prevent such errors, yet these guidelines were not adhered to, leading to the deficiencies observed.
Failure to Identify and Treat Skin Conditions
Penalty
Summary
The facility failed to identify and treat new venous ulcers, ensure physician oversight, and accurately assess a change in skin condition for two residents. Resident #21 was observed with swollen legs and feet, with visible drainage and open areas on the feet, indicating untreated venous ulcers. Despite having physician orders for wound care, there was no documentation of treatment for the feet, and the physician's progress notes did not mention any wounds. The nursing staff, including LPNs and the DON, were aware of the condition but failed to provide appropriate care or documentation, citing the resident's refusal of care as a reason. Resident #12 reported abdominal itching and groin irritation for three weeks, requesting Nystatin powder, which had been used previously for similar issues. Despite informing nursing staff and a doctor, no action was taken, and no orders for treatment were found in the resident's records. Upon assessment, the resident's skin showed signs of irritation, confirming the resident's complaints. The DON was unaware of the issue until informed by the surveyors, indicating a lack of communication and follow-up on the resident's concerns. The facility's policies on skin management and physician involvement were not followed, as evidenced by the lack of documentation and treatment for the residents' skin conditions. The DON admitted to not having a wound nurse or contracting with an outside provider, placing the responsibility on the attending physician and herself. The failure to assess, document, and treat the residents' skin conditions highlights significant deficiencies in the facility's care processes.
Controlled Substances Not Securely Stored Due to Broken Lock
Penalty
Summary
The facility failed to ensure that controlled substances were stored in locked compartments in the 400-Hall, which could potentially affect all residents with prescribed controlled substances in that area. A discrepancy was noted in the count of Klonopin, a Schedule IV anti-anxiety medication, where the count decreased from 25 to 22 without any signature accounting for its administration. Interviews revealed that the lock on the controlled substance box was broken, and although the Director of Nursing (DON) was aware and a work order was put in, the medications were not moved to a secure box. Interviews with staff members, including RN E, LPN A, LPN B, and RN G, indicated varying levels of awareness and communication about the broken lock. RN E was informed by the day shift nurse about the broken lock, and RN G confirmed receiving a report about it. The Maintenance Director confirmed replacing the lock after a work order was created by the DON. The facility's policy requires controlled substances to be stored in a double-locked compartment, which was not adhered to in this instance.
Misappropriation of Controlled Substance in LTC Facility
Penalty
Summary
The facility failed to prevent the misappropriation of a controlled substance medication for one resident, identified as R401, who was prescribed clonazepam for conditions including generalized anxiety disorder, dementia with behavioral disturbance, and bipolar disorder. The discrepancy was noted when the controlled substance count sheet for R401's clonazepam showed a reduction from 25 to 22 tablets without proper documentation or signatures accounting for the administration of the medication. The facility's policy on abuse, neglect, and misappropriation of resident property defines misappropriation as the wrongful use of a resident's belongings or money without consent. Interviews with staff revealed that the discrepancy was discovered during routine medication counts conducted by LPN A and RN G. LPN A did not notice the discrepancy during her shift as R401's medication was only administered at night. When the count was off, LPN A and LPN B documented the actual count and notified the DON. RN G, who was involved in the medication count, did not notice the discrepancy until the count was conducted with LPN A. A urine drug test for RN G did not include testing for benzodiazepines, and the facility's investigation into the missing medication was inconclusive, with two clonazepam tablets unaccounted for.
Failure to Timely Identify and Treat Wrist Fracture
Penalty
Summary
The facility failed to identify and treat a wrist fracture in a timely manner for a resident (R701) who experienced multiple falls and made an allegation of abuse. The resident was observed with a cast on his left arm and reported pain when not taking pain medication. The clinical record revealed that the resident had a fracture of the left wrist and hand, and a displaced fracture of the left ulna, diagnosed on 4/10/24. Despite multiple falls and complaints of pain, the facility did not seek timely treatment or diagnostic tests to rule out a fracture until 4/1/24, when an X-ray was finally ordered and confirmed the fracture on 4/2/24. The resident's clinical record showed several instances where the resident fell, complained of pain, and exhibited swelling and bruising on the left wrist. On 2/24/24, the resident alleged abuse, stating he was hit and fell, hurting his wrist. Despite this, the physician did not order an X-ray, citing no palpable pain and normal range of motion. The resident continued to experience pain and swelling, with multiple progress notes documenting these symptoms, but no further diagnostic tests were ordered until the end of March. Interviews with staff and the resident's family member revealed that the resident's wrist was visibly deformed and swollen, and the family member expressed concerns about the lack of timely medical intervention. The Director of Nursing acknowledged awareness of the resident's condition and falls but stated that they followed the physician's orders, which did not include an X-ray. The facility's policy on acute condition changes emphasized the need for detailed observations and timely communication with the physician, which was not adequately followed in this case.
Failure to Evaluate and Assess Pressure Ulcers
Penalty
Summary
The facility failed to ensure a physician or physician extender evaluated and assessed pressure ulcers for a resident (R702). R702 was admitted with diagnoses including a right femur fracture and hypertension, and initially had no pressure ulcers. However, on 7/2/23, a wound progress note indicated red, slow-to-blanch, boggy heels bilaterally, and a red, blanching sacrum and coccyx. Despite this, there was no documentation of a Deep Tissue Injury (DTI) or orders for treatments or heel lift protectors until 7/12/23. By 7/9/23, R702 had developed a Stage 2 sacrum pressure ulcer and a DTI to the right heel. The physician progress notes from Dr. J and NP K did not mention these pressure ulcers or injuries, and both medical professionals indicated they focused on the resident's primary reason for admission rather than the pressure ulcers unless specifically notified by nursing staff. Interviews with Dr. J and NP K revealed that they relied on nursing staff to notify them of wound issues and typically did not assess or evaluate pressure ulcers unless there was a specific concern such as infection or the need for debridement. The facility's policy on physician services indicated that the attending physician should participate in the resident's assessment and care planning, including monitoring changes in the resident's medical status and providing consultation or treatment. However, this policy was not followed in the case of R702, leading to a lack of proper evaluation and treatment of the resident's pressure ulcers.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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