Wellspring Lutheran Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Frankenmuth, Michigan.
- Location
- 725 West Genesee, Frankenmuth, Michigan 48734
- CMS Provider Number
- 235269
- Inspections on file
- 20
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Wellspring Lutheran Services during CMS and state inspections, most recent first.
The facility did not install appropriate backflow prevention on cross connections, including a hose with a spray nozzle connected downstream of an AVB in the kitchen and chemical feed dispensers lacking wasting tees in janitor's closets. The Director of Maintenance was unfamiliar with certain backflow prevention requirements, leading to noncompliance.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
The facility failed to promptly assess and respond to abnormal vital signs in a resident with cardiac conditions, delayed antibiotic therapy for another resident due to incomplete medication reconciliation at admission, and did not ensure timely completion of a STAT abdominal x-ray or appropriate monitoring for a third resident with post-surgical complications, resulting in delayed treatment and hospital transfer.
The facility was found to have significant deficiencies in maintaining a safe and sanitary environment, including mold in the kitchen ice machine, unsanitary conditions in the Garden View unit, and extensive mold issues in the basement. An independent lab report confirmed the presence of harmful molds, and the facility's boiler licenses were expired. The maintenance director acknowledged ongoing issues with mold and leaking pipes, citing a lack of resources and policy for addressing these problems.
The facility's kitchen was found to have multiple sanitation deficiencies, including unclean equipment, improper food storage, and incomplete cleaning documentation. Observations included a lack of soap and paper towels at a hand sink, food residues on equipment, improperly stored meat, and mold-like substances in the ice machine. The Dietary Manager acknowledged these issues, and the facility lacked a documented cleaning policy for the ice machine.
The facility failed to ensure resident dignity during a physician's visit, where a personal conversation about pain management was overheard by others in the dining room. Additionally, the facility did not respond to call lights promptly and failed to address a resident's grievance, resulting in embarrassment and loss of dignity.
A facility failed to provide a complete Notice of Medicare Non-Coverage and Advanced Beneficiary Notice of Non-Coverage to a resident, leading to a lack of information about appeal rights and potential financial hardships. The resident, who was alert and oriented, continued their stay under private pay after Medicare coverage ended. Staff interviews revealed a misunderstanding about the necessity of issuing the SNF ABN, and the facility's policy was not provided during the survey.
A resident with a history of Alzheimer's and other conditions experienced a fall resulting in a fracture, which was not promptly addressed in her care plan. Despite ongoing complaints of pain and x-ray confirmation of fractures, the facility failed to update the care plan to reflect these changes. The DON acknowledged the oversight, which led to inadequate pain management.
A long-term care facility failed to conduct thorough investigations for injuries of unknown origin for two residents, leading to incomplete investigations and potential recurrence of injuries. One resident with a history of falling was found with skin tears, and the facility did not determine the cause or interview staff. Another resident suffered a fracture not immediately identified, with the facility incorrectly attributing it to an earlier fall. The investigation process was flawed, lacking proper documentation, interviews, and timely reporting.
A resident with a history of stroke, dementia, and multiple sclerosis experienced significant unassessed weight loss due to the facility's failure to provide meals as ordered and notify the physician. The resident's care plan, which included specific dietary preferences like grilled cheese, was not followed, leading to low meal intake and frequent refusals. The staff acknowledged the oversight but did not ensure the resident received the full meal tray. Additionally, there was a lack of communication and documentation regarding the resident's condition, with no notification to the physician or family about the weight loss.
The facility failed to maintain a CPAP machine for a resident with obstructive sleep apnea, as it was not cleaned or bagged according to protocol. Additionally, another resident with COPD and heart disease did not receive oxygen therapy as ordered, with their oxygen tank improperly set and tubing not in use. Both deficiencies highlight lapses in respiratory care and care planning.
A nurse failed to follow proper insulin pen administration procedures for a resident, not waiting the required 5 to 10 seconds after injection before withdrawing the needle, potentially affecting insulin absorption.
The facility failed to secure and label medications on the Garden View unit, with an unlocked treatment cart and un-labeled Hydrocortisone cream. Additionally, the Morning [NAME] unit did not maintain proper temperature logs for medication refrigerators, with missing entries and failure to follow required procedures.
Failure to Ensure Proper Backflow Prevention on Cross Connections
Penalty
Summary
The facility failed to ensure proper backflow prevention on cross connections, as observed during an inspection. A hose with an attached spray nozzle was found connected to a water line downstream of an atmospheric vacuum breaker (AVB) in the kitchen near the dishwasher, which is not compliant with backflow prevention standards. Additionally, chemical feed dispensers supplied by utility sinks with AVBs, but lacking attached wasting tees, were observed in multiple janitor's closets. The Director of Maintenance was knowledgeable about the cross connection in the kitchen but was unfamiliar with the requirement for a wasting tee or bleeder device on the chemical feed dispensers. These deficiencies were identified through observation, interview, and record review.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular residents or events involved.
Failure to Timely Respond to Change in Condition, Abnormal Vitals, and Antibiotic Administration
Penalty
Summary
The facility failed to provide timely and appropriate care in response to changes in condition and abnormal vital signs for multiple residents. For one resident with a history of heart failure, atrial fibrillation, and hyperkalemia, there were repeated instances of abnormal pulse readings documented in the medical record, including bradycardia with heart rates as low as 37 bpm. Despite these abnormal findings, there was no evidence of reassessment, practitioner notification, or follow-up interventions documented. Interviews with the nurse practitioner and DON confirmed that the facility's policy required reassessment and provider notification for out-of-range vital signs, but this was not carried out as required. Another resident, admitted for rehabilitation with diagnoses including cellulitis and UTI, experienced a three-day delay in receiving prescribed antibiotics after transfer from the hospital. The resident reported the delay to staff, and it was discovered that the antibiotic was not ordered because it was missing from the medication list, despite being included in the hospital discharge summary and physician progress notes. The DON and ADON confirmed that the facility's process relied solely on the medication list for new admissions, and did not include review of the discharge summary or progress notes, resulting in the omission and delay of critical antibiotic therapy. A third resident, admitted following hernia surgery and with a history of COPD, experienced a decline in condition characterized by abnormal vital signs, including low blood pressure, high pulse, increased respiratory rate, decreased oxygen saturation, and persistent abdominal pain, nausea, and vomiting. Although a STAT abdominal x-ray was ordered, the order was not processed as STAT, resulting in a delay of over 24 hours before the x-ray was completed and results were communicated. Documentation did not reflect timely assessment or intervention in response to the resident's abnormal vital signs or worsening symptoms, and the resident was ultimately transferred to the hospital after continued decline.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment, as evidenced by the presence of mold and unsanitary conditions in various areas. During an environmental tour, surveyors observed a black mold-like substance on the kitchen ice machine, which had not been cleaned as per the facility's schedule. Additionally, a public bathroom lacked paper towels, and a fan with black dirt on its blades was blowing air toward the nursing station. In the Garden View unit, soiled linens were improperly stored, and a dehumidifier's filter was heavily dust-laden. A small shower room emitted a sewer-like smell due to an open drain. In the basement, significant mold issues were identified, including black mold-like areas on ceiling tiles in the medical records room, therapy storage room, and staff education room. The medical records room also had buckets collecting water from leaking pipes, with visible mold on the ceiling. An independent lab report confirmed the presence of Chaetomium and Stachybotrys molds, which are known to cause respiratory symptoms and other health issues. The facility's maintenance director acknowledged the ongoing issues with mold and leaking pipes, citing a lack of resources and policy for addressing these problems. Furthermore, the facility's boiler licenses were found to be expired, with the maintenance director admitting to giving up on contacting state inspectors. The environmental service manager's job description emphasized the importance of maintaining the building and equipment to protect the safety and health of residents, employees, and visitors, highlighting a failure to meet these essential duties.
Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which could potentially affect all 53 residents consuming meals prepared there. During an initial tour of the kitchen, several deficiencies were observed. The kitchen hand sink near the ice machine and dish area lacked soap and paper towels, and the Dietary Manager did not replenish these supplies. Equipment such as a large metal can opener and a Robot Coupe food processor were found with food residues, and a heavy-duty blender had dust on it. A large pan of individually wrapped steaks was left at room temperature without any date or time labels, and a white plastic bin containing thickener was also unlabeled. Additionally, a small trash bin was placed on a food prep table next to open food items, and spice containers were sticky and dirty. Further observations revealed that clean dishes were improperly stored while still wet and with food residues. The kitchen ice machine had a black mold-like substance on the seal tape and a dried yellow substance inside, indicating it had not been cleaned as per the facility's schedule. The facility's kitchen cleaning checklists were incomplete, with several areas left blank and undated. The Dietary Manager acknowledged the lack of documentation and the absence of a policy for kitchen ice machine cleaning was noted during the survey.
Failure to Ensure Resident Dignity and Timely Response
Penalty
Summary
The facility failed to uphold the dignity of its residents in several instances. During a physician's visit, a resident was engaged in a personal conversation about their pain management in the main dining room, where other residents and visitors could overhear. This lack of privacy was confirmed by a visitor who expressed discomfort at the personal nature of the discussion being overheard. Additionally, the facility did not respond to call lights in a timely manner, as reported in a Confidential Resident Group Meeting. Furthermore, a grievance from another resident was not addressed, leading to feelings of embarrassment and loss of dignity for the resident involved.
Failure to Provide Complete Beneficiary Notices
Penalty
Summary
The facility failed to provide a complete Notice of Medicare Non-Coverage (NOMNEC) and the Advanced Beneficiary Notice of Non-Coverage (SNF ABN) to a resident, resulting in the resident and/or their representative not being informed of their right to appeal and the potential for undue emotional and financial hardships. The resident, who was alert and oriented, was admitted with Medicare Part B coverage, which ended on February 12, 2024. Although the NOMNEC was issued on February 8, 2024, it was provided too early, and the SNF ABN was not included in the resident's notification file. The resident chose to stay at the facility and pay out-of-pocket after the last covered day, eventually being discharged under private pay insurance status. Interviews with facility staff revealed a misunderstanding regarding the issuance of the SNF ABN. The accounts payable staff, responsible for issuing NOMNEC letters, did not issue the SNF ABN, believing it was unnecessary since the resident opted to go home. The social services manager also did not issue the SNF ABN, as they believed it was not needed due to the resident's decision to discharge themselves. The facility's policy on Beneficiary Notice of Medicare Non-Coverage and the Advanced Beneficiary Notice of Non-Coverage was requested but not provided before the survey exit date.
Failure to Revise Care Plan for Pain Management
Penalty
Summary
The facility failed to review and revise the care plan for a resident who experienced significant changes in her condition, specifically related to pain management. The resident, who was alert and oriented with a BIMS score of 11/15, had a history of Alzheimer's Disease, Dementia, Type 2 Diabetes, and Generalized Anxiety Disorders. She was admitted with these diagnoses and later suffered a fall, resulting in a fracture that was not immediately addressed in her care plan. On June 27, 2024, the resident was observed to be in pain due to a spiral fracture of the right tibia and fibula, which was confirmed by x-ray. Despite the resident's ongoing complaints of pain and the significant findings from the x-ray, the facility did not update her care plan to reflect these changes. The Medication Administration Record showed fluctuating pain levels, but there was no documentation of follow-up or effectiveness of pain interventions. The Director of Nursing admitted that the care plan was not revised to address the resident's severe pain and fractures. The facility's policy required care plans to be reviewed and revised as needs change, but this was not done in a timely manner. The lack of revision in the care plan resulted in the potential for unmet needs and inadequate pain management for the resident.
Inadequate Investigation of Injuries in LTC Facility
Penalty
Summary
The facility failed to conduct thorough investigations for injuries of unknown origin for two residents, resulting in incomplete investigations and the likelihood of injuries reoccurring. Resident #27, who has a history of falling, diabetes, and dementia, was found with two skin tears on her left leg. The facility's investigation was inadequate as it did not determine how the injuries occurred, and there were no interviews or statements from staff who might have witnessed the incident. The Director of Nursing (DON) admitted that the investigation was not thorough, and the facility did not provide additional documentation to explain the cause of the injuries. Resident #11, who has Alzheimer's disease, dementia, and other diagnoses, suffered a fracture that was not immediately identified. After a fall on June 10, 2024, an x-ray showed no fracture, but the resident continued to experience pain. A subsequent x-ray on June 27, 2024, revealed a fracture, but no incident report was created in the electronic medical record. The facility concluded that the fracture was from the original fall, despite evidence suggesting otherwise. The investigation lacked interviews with relevant staff, including those from the rehab department, and did not include a comprehensive review of the resident's care and therapy sessions. The facility's investigation process was flawed, as evidenced by the lack of proper documentation, interviews, and timely reporting. The Assistant Director of Nursing (ADON) conducted interviews informally without collecting written statements or signatures. The investigation summary was incomplete, lacking the author's name, signature, and date of completion. The Administrator and DON acknowledged the deficiencies in the investigation process, admitting that the procedures followed were not acceptable and did not adhere to the facility's policies for investigating and reporting injuries of unknown origin.
Failure to Provide Adequate Nutrition and Notify Physician of Weight Loss
Penalty
Summary
The facility failed to provide adequate nutrition and follow care planned interventions for a resident, resulting in significant unassessed weight loss. The resident, who had a history of stroke, dementia, and multiple sclerosis, required assistance with all activities of daily living and had severely impaired cognition. Observations revealed that the resident's meals were not provided as ordered, with missing main lunch meals and specific dietary requests such as grilled cheese not being fulfilled. The resident's weight had decreased significantly over several months, with no weights recorded for January and February, and there was no documentation that the physician was informed of this weight loss. The dietary staff did not adhere to the resident's care plan, which included providing a regular diet with specific preferences like grilled cheese and cottage cheese. Despite the resident's preference for these items, they were not consistently offered, and the resident's meal intake was low, with frequent refusals noted. The staff, including the server and registered dietician, acknowledged the oversight but failed to ensure the resident received the full meal tray as per the care plan. The server admitted to downsizing portions and not following the meal ticket, while the dietician confirmed that the grilled cheese was on the care plan but not on the meal ticket. Additionally, there was a lack of communication and documentation regarding the resident's condition. The physician was not notified of the significant weight loss, and the family was not informed either. The facility's weight measurement policy required documentation of physician and family notification, but this was not followed. The resident's decreased appetite and meal intake were noted, but appropriate actions to address these issues were not taken, leading to continued weight loss and potential health risks.
Deficiencies in Respiratory Care and Oxygen Therapy
Penalty
Summary
The facility failed to ensure proper maintenance and usage of a CPAP machine for a resident who required it for obstructive sleep apnea. The resident, who was admitted for rehabilitation after hip surgery, had a CPAP machine that was not cleaned or bagged as per the facility's protocol. The resident reported that they had not been offered assistance to clean the CPAP machine, which had not been cleaned for six days, including four days while at the facility. The CPAP care plan was not established until the day of the survey, despite the resident's need for nightly CPAP use. Additionally, the facility did not ensure that another resident received oxygen therapy as ordered. This resident, who had chronic ischemic heart disease, COPD, and Alzheimer's disease, was observed without their oxygen nasal cannula on multiple occasions. The resident's oxygen tank was not set to the prescribed 3 liters per minute, and the resident was found sitting on their oxygen tubing. Despite being reminded of the need for assistance, the resident's oxygen levels were not adequately monitored, and the oxygen care plan was not updated to reflect the current needs.
Improper Insulin Pen Administration
Penalty
Summary
The facility failed to ensure proper insulin pen administration for a resident, leading to the likelihood of decreased insulin absorption and continued misadministration. During a medication administration task, a nurse was observed preparing and administering insulin to a resident. The nurse dialed the insulin pen to the required dose and injected it into the resident's abdomen. However, the nurse did not wait the required 5 to 10 seconds after pushing the plunger before withdrawing the needle, completing the process in only 3 seconds. This action was contrary to the facility's insulin pen administration instructions, which specify holding the pen in the skin for the additional time to ensure the entire dose is dispensed into the subcutaneous tissue.
Medication Security and Temperature Log Deficiencies
Penalty
Summary
The facility failed to ensure proper security and labeling of medications on the Garden View unit. During an observation, the treatment cart was found unlocked with no nurse present, and a tube of Hydrocortisone cream was discovered un-labeled, un-dated, and without a cap. Additionally, nail clippers and scissors were found in the top drawer of the cart. Nurse LPN D, who was in a resident's room at the time, acknowledged the oversight but was unsure how the cart became unlocked. The Director of Nursing (DON) indicated that the second shift nursing staff was responsible for cleaning and dating medications on the carts, but no policy for cleaning medication carts was available. The facility also failed to maintain proper temperature logs for medication refrigerators on the Morning [NAME] unit. Observations revealed that the temperature log for the medication refrigerator had not been documented for the current day, with the last entry being from the previous morning. Another refrigerator's temperature log showed the last check was two days prior. The facility's refrigerator log instructions require exact temperatures to be recorded twice daily, with minimum and maximum temperatures noted once daily, and immediate action to be taken if temperatures are out-of-range. However, these procedures were not followed, as evidenced by the incomplete logs.
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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