Willowbrook Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Flint, Michigan.
- Location
- G-4436 Beecher Road, Flint, Michigan 48532
- CMS Provider Number
- 235550
- Inspections on file
- 34
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Willowbrook Manor during CMS and state inspections, most recent first.
A resident admitted with a UTI and multiple comorbidities was ordered to receive only two doses of Nitrofurantoin 100 mg q12h to complete antibiotic therapy, but review of the EMR and MAR showed that staff entered and followed orders resulting in administration of a total of ten doses over several days, with some scheduled doses also missed. After this extended antibiotic administration, the resident reported vaginal itching, burning, and white discharge, and providers documented candidiasis and a vaginal yeast infection, ordering Diflucan and miconazole suppositories. During interviews, the ADON confirmed the original intent was for only two doses and could not explain why so many doses were given, and the DON reported no additional information to account for the excess dosing, despite care plans directing that medications be administered as ordered and residents monitored for side effects.
Multiple residents with complex medical needs, including dependence on supplemental O2, impaired mobility, and need for assistance with toileting and hygiene, experienced prolonged and inconsistent responses to call lights. In one case, a resident on O2 developed headache, dizziness, and lightheadedness after an O2 tank ran empty and waited about 25 minutes after activating the call light before staff responded and then left to find a full tank. Another resident with a prior hip fracture and moderate cognitive impairment was found on the floor with pants down after not receiving timely toileting assistance, and family reported waiting over 30 minutes for call light response, leading them to toilet and clean the resident themselves. Other cognitively intact residents reported and demonstrated call light waits of 30 minutes to an hour, malfunctioning or improperly connected call lights, and staff turning off call lights without completing requested care, such as incontinence care, even when the activated lights were visible from the nurse’s station. Resident council minutes documented repeated complaints over several months about long call light response times, despite facility policy and leadership statements that call lights should be answered promptly and remain on until needs are met.
Surveyors identified that respiratory care orders and procedures were not consistently followed for three residents. A resident receiving nebulizer treatments for COPD had the nebulizer mask, tubing, and medicine chamber stored wet inside a plastic bag, despite facility policy requiring rinsing and air-drying. Another resident, cognitively intact and dependent on staff for several ADLs, was left without prescribed continuous O2 after a CNA-assisted clothing change, with the nasal cannula left out of reach and an SpO2 of 87–88% when staff were notified. A third resident on supplemental O2 was observed receiving 4 L/min via concentrator, while the physician’s order specified 2 L/min, and the facility’s oxygen policy lacked direction on adhering to provider-ordered O2 flow rates.
A resident with multiple complex diagnoses experienced an acute change in condition, including unresponsiveness, high fever, and labored breathing. Facility staff failed to promptly recognize and respond to these changes, with delayed transfer to the hospital and insufficient monitoring and documentation of vital signs and Foley catheter status. Communication lapses and lack of clear care plan interventions contributed to the deficiency.
Surveyors found that multiple residents experienced prolonged call light response times, lack of follow-up on grievances, and dissatisfaction with food quality and snack distribution. Residents reported being left soiled for extended periods, staff ignoring call lights, and call lights being inaccessible. Documentation of Resident Council meetings showed persistent unresolved issues and lack of administrative follow-up.
A group of residents reported unresolved grievances regarding prolonged call light response times, poor food quality, lack of bedtime snack distribution, limited group activities, and staff availability and attitude. Residents were unaware of the grievance process or forms, and review of meeting minutes showed a lack of documentation and follow-up on concerns. The Administrator was not aware of her role in addressing council issues, and specific complaints included unaddressed dietary needs and inadequate staff response.
A group of residents reported that HS snacks were not consistently provided or distributed, with some only receiving them if they went to the nurse's station. One resident with diabetes was unaware of the availability of HS snacks and never received them. Resident Council meeting minutes showed missing documentation and no follow-up on concerns, and the Administrator was unaware of the issues and had not documented meeting postponements or resolutions.
Surveyors identified several deficiencies in kitchen sanitation and food safety, including outdated and unlabeled food items, improper refrigerator and freezer temperatures, incomplete temperature logs, dented cans stored with other food, and improper storage of ice scoopers. Additionally, a spider and web were found on the grill, highlighting lapses in cleanliness. These issues were acknowledged by the dietary manager and discussed with the Administrator.
The facility did not ensure that advance directives and code status were properly assessed, documented, and signed for two residents. One resident's code status assessment was missing from the care plan and not signed by the resident, while another resident's DNR order was not signed by a physician and the previous order had expired. Facility policy requiring timely and complete documentation was not followed, resulting in incomplete records for both residents.
Two residents did not receive care as ordered: one did not receive the prescribed collagen/silver dressing for a facility-acquired pressure ulcer due to supply issues, and another did not receive her ordered antihypertensive medication for several days because it was unavailable from the pharmacy. Nursing staff were aware of the issues but did not ensure the correct treatments were provided as recommended by the wound clinic and physician.
Two residents experienced deficiencies in nutrition management when the facility failed to update care plans for actual weight loss and did not consistently follow dietary orders for increased protein portions. One resident lost significant weight without a care plan addressing the loss, while another did not receive prescribed double protein portions and had declining albumin levels, with care plans and documentation not reflecting these needs.
A resident with dementia and hemiplegia was unable to use an ill-fitting lower partial denture for an extended period, resulting in ongoing difficulty chewing certain foods. Despite repeated documentation of the issue in dental records and staff awareness, no timely dental adjustment or dietary modification was made, and the resident remained on a regular diet. This failure to provide prompt dental services and ensure adequate nutrition was not in accordance with facility policy.
The facility did not ensure that emergency preparedness policies and procedures matched actual resources and practices. Staff were directed to use an emergency kit cart in a location where it was not present, and the severe weather policy referenced a weather radio at the main nurse station that did not exist. These discrepancies were confirmed during record review and interview with the maintenance director.
Surveyors found that battery back-up emergency lighting over transfer switches and in the activities area did not illuminate when tested, leaving critical areas without emergency lighting during a power outage. The maintenance director confirmed these findings during the inspection.
A deficiency was identified when the sprinkler escutcheon ring in the main office paper supply closet was found to have slid down around the sprinkler head, preventing proper sprinkler function. This issue was confirmed by the maintenance director and indicated a failure to maintain the sprinkler system according to NFPA 25 requirements.
The facility did not perform a full annual inspection and testing of all rated swinging fire doors, as only the cross corridor fire doors were included while other rated doors, such as those for storage and utility rooms, were omitted. This was confirmed by the maintenance director during record review.
Surveyors identified that the facility's automatic transfer switch for the equipment branch was not functioning and had been out of service for several months, as confirmed by the maintenance director. Additionally, the facility could not provide documentation of annual servicing or load bank testing for the back-up emergency generator, with the maintenance director stating that paperwork from a recent generator company visit was not yet available.
Surveyors found that multiple emergency exits were inaccessible or obstructed, including a sealed exterior door, a corridor blocked by dialysis transport chairs, and a stuck exit door from the main dining room. These issues were confirmed by the maintenance director during the inspection.
Exit signs in the older section of the facility failed to illuminate when tested for battery back-up, indicating they were not transferring to emergency power as required. The maintenance director believed the signs were working, but testing and observation confirmed the deficiency, which could affect 50 occupants during a power outage.
During a survey, it was observed that the soiled utility room door in the 600 hall did not latch when closed, failing to meet requirements for hazardous area fire barrier protection. This deficiency was confirmed with the maintenance director and could allow smoke or fire to escape into the emergency egress corridor.
Double rated fire corridor doors outside a resident room were found unable to fully close because of a failing door arranger, compromising their ability to resist smoke passage as required by NFPA standards. This deficiency was confirmed by the maintenance director and could affect 50 occupants by allowing smoke and fire to transfer between compartments.
A resident who required a Fentanyl patch for pain management went without the medication for three days after the patch fell off and the facility failed to obtain a new prescription in a timely manner. The resident experienced increased pain and frustration due to the lack of communication and delay in reordering the controlled substance, with documentation showing missed doses and unsuccessful attempts to secure a new script.
The facility failed to properly manage IV Vancomycin therapy for two residents, resulting in subtherapeutic levels for one and overdosing for another. Miscommunication with the pharmacy and lack of documentation led to these deficiencies, as the facility did not have a clear policy for managing IV medications.
A facility failed to assess, monitor, and document wounds for a resident with diabetes and other health issues, leading to the development of necrotic and abraded areas on the resident's toes. Despite an orthopedic consult identifying a wound, there was no documentation or physician orders in the medical records. The facility's care plans and policies for regular skin assessments were not followed, and the Director of Nursing acknowledged the oversight.
A facility failed to update the catheter status and documentation for a resident, leading to staff being unaware of the resident's actual catheter status. Despite the removal of the catheter, orders were not discontinued, and staff continued to document catheter care. The care plans did not reflect the removal, and the facility's policy lacked guidance on discontinuation. Interviews confirmed the discrepancy between the resident's actual status and the documentation.
The facility's kitchen was found to have multiple deficiencies, including mold-like accumulation on wire racks, a leaking steamer, and improper maintenance of a backflow prevention device. An opened soy sauce jug was improperly stored, and the walk-in freezer door gasket was damaged with excessive ice build-up. Additionally, a spray bottle was not labeled, posing a risk of contamination.
The facility failed to ensure accurate advance directive information for two residents, leading to potential non-compliance with their medical care preferences. One resident had a DNR order without a required declaration of incompetence, while another's advance directive lacked necessary witness signatures. These deficiencies highlight the facility's failure to adhere to policies and state requirements.
A resident was observed with a half lap tray attached to their wheelchair without a prior assessment to determine if it was a restraint or enabler. The facility's policy required an evaluation, a signed consent, and a current order specifying the restraint's use, none of which were met. The care plan was not updated to reflect the assessment findings.
Two residents in the facility had deficiencies in their care plans. One resident's care plan lacked specific side effects for Seroquel and Zoloft, while another resident's care plan was not updated for a new Zoloft order and did not specify the medical reason for a half lap tray on their wheelchair. A physical restraint assessment was missing until completed during the survey.
The facility failed to provide adequate ADL care for three residents, resulting in unmet hygiene needs. A resident with severe cognitive impairment had long, dirty nails and dry skin, while another resident, cognitively intact, reported not receiving preferred showers and was observed with greasy hair. A third resident, also cognitively intact, had long, dirty fingernails and reported not receiving oral care or scheduled showers. Documentation inconsistencies were noted in all cases.
A facility failed to perform dressing changes and remove a PICC line as ordered for a resident with neurogenic bladder and sepsis. The resident's PICC line dressing was dirty and peeling, and the line was not removed despite a physician's order. Staff were unaware of the resident's PICC line status, leading to a lapse in care.
The facility failed to implement proper interventions for pressure ulcer care for two residents. One resident's feet were pressed against a bed obstruction, leading to a pressure ulcer, while another resident's wound care was not performed as scheduled. Care plans for floating heels and using pressure reduction mattresses were not consistently followed, and documentation was incomplete.
A resident with a history of depression and anxiety did not receive necessary behavioral health interventions. Despite recommendations for socialization and meaningful activities, the resident was isolated, with no 1:1 visits in the past 30 days. The Activities Director confirmed the resident was not on the 1:1 visit list, leading to a lack of necessary care.
Two residents experienced medication administration errors, leading to a 20.69% error rate. A resident received insulin after eating, contrary to orders, and another resident's medication was delayed without notifying the physician. Additionally, an LPN left medications unattended on a sleeping resident's table.
A resident with osteomyelitis did not receive prescribed Vancomycin doses due to documentation errors and delays in receiving necessary lab results. The ADON acknowledged the issue and noted that staff education on proper charting was conducted.
A resident expressed dissatisfaction with the temperature of meals served at the facility. During an observation, the Certified Dietary Manager found that the fish, cauliflower, and potatoes on the resident's tray were below the required temperature of 140°F, while the apple pie was at an appropriate temperature. The resident, who was cognitively intact and had multiple diagnoses, reported that the food was frequently cold.
A facility failed to coordinate hospice services for a resident with multiple diagnoses, including COPD and prostate cancer. The resident was unable to explain the hospice service schedule, and no hospice calendar was present in the room. The plan of care lacked details on hospice disciplines and frequency, and the Kardex did not indicate hospice services. Staff interviews revealed confusion about the hospice schedule, with two undated calendars in a notebook and no clear indication of which was accurate. The resident had not received a hospice calendar, contrary to facility policy.
The facility failed to implement effective pressure ulcer prevention and management for two residents, leading to the development and worsening of facility-acquired pressure ulcers. One resident developed a Stage III ulcer on their left buttocks due to inadequate interventions and documentation, while another developed a Stage III ulcer on their left heel, with staff unaware of the ulcer and necessary preventive measures. The facility's policies were not effectively implemented, resulting in unnecessary pain and health decline.
The facility failed to properly monitor and maintain emergency medical equipment, resulting in expired and unsanitary items in two emergency carts. The central crash cart had mismatched lock numbers and contained expired medications, while the 600-hall cart had expired supplies and lacked essential items. The AED was soiled, and the facility's policy did not ensure consistent stocking of necessary supplies, potentially delaying emergency care.
A facility failed to prevent and investigate abuse allegations involving a CNA and three residents. One resident reported sexual abuse and neglect, while two others experienced physical abuse and intimidation. The facility's investigation was inadequate, with no suspension of the accused CNA and insufficient documentation of the incidents.
Excess Nitrofurantoin Dosing and Subsequent Yeast Infection
Penalty
Summary
The deficiency involves the facility’s failure to administer medications as ordered for a resident admitted with multiple diagnoses including diabetes, hypothyroidism, arthritis, dementia, history of falls, low back pain, hypertension, history of stroke, and a UTI. Hospital discharge instructions and a nurse practitioner note specified that the resident was to receive Nitrofurantoin 100 mg every 12 hours for a total of two doses to complete treatment for a UTI after admission. The physician orders in the facility’s EMR reflected Nitrofurantoin 100 mg twice daily for UTI for two administrations with a start date of 1/7/2026, and a second, similar order with a start date of 1/12/2026. Review of the January MAR showed the resident actually received 7 doses of Nitrofurantoin from 1/7/2026–1/11/2026, with missed doses on the morning of 1/9/2026 and the evening of 1/11/2026, and then 3 additional doses from 1/12/2026–1/13/2026 under the new order, for a total of 10 doses instead of the 2 doses ordered. Subsequently, provider encounter notes documented that the resident reported symptoms consistent with a yeast infection, including vaginal itching, burning, and white discharge. On 1/13/2026, a physician documented candidiasis and ordered Diflucan, and on 1/15/2026 an NP documented a vaginal yeast infection with intense itching and white discharge and ordered Diflucan and miconazole vaginal suppositories, which were initiated on 1/16/2026. The ADON, when interviewed, confirmed she had entered the Nitrofurantoin order for two doses and stated she did not know why the resident received so many doses, acknowledging that the resident developed a yeast infection and was very uncomfortable after receiving extra antibiotic doses. The DON reported there was no additional information explaining why more Nitrofurantoin doses were given than ordered. The resident’s care plans included interventions to administer medications as ordered and observe for side effects and effectiveness for both the UTI and subsequent vaginal yeast infection.
Failure to Ensure Timely and Effective Call Light Response for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to timely response to call lights and basic care needs for multiple residents. One resident with heart failure, atrial fibrillation, COPD, and dependence on supplemental O2 experienced an oxygen concentrator malfunction and was placed on an oxygen tank that subsequently ran out. The resident developed a headache, dizziness, and lightheadedness, activated the call light, and waited approximately 25 minutes before staff responded. When staff did respond, they left the room to locate a full oxygen tank, placing the resident at serious risk of harm and demonstrating a failure to ensure basic medical safety and timely response. Another resident with a history of femur fracture, muscle disorders, falls, and moderately impaired cognition (BIMS 9/15) was dependent on staff for toileting and lower body dressing. Confidential persons reported that this resident needed to use the bathroom, was not attended to, and was later found on the floor of another resident’s room with pants down below the knees. A confidential person also reported activating the call light during a visit and waiting more than 30 minutes with no staff response, ultimately taking the resident to the bathroom themselves. They reported that staff became upset and stated visitors should wait for staff, but the resident could not hold it that long, would try to get up alone, and had multiple incontinence episodes while waiting for staff. The confidential person also reported finding the resident incontinent of bowel and changing the resident themselves due to long response times. A resident with stroke, diabetes, depression, and hemiplegia/hemiparesis, cognitively intact (BIMS 14/15) and dependent on staff for hygiene, toileting, bathing, dressing, mobility, and transfers, reported having a call light on for about 30 minutes with no staff entering the room. Observation showed the wall call light illuminated for the roommate, who denied activating it, while the resident’s own call light did not activate when pressed multiple times. Maintenance later adjusted the wall connection before the call light functioned. This resident reported that call light wait times could exceed 30 minutes and sometimes take up to an hour when calling for assistance after incontinence and for ice water. Another cognitively intact resident (BIMS 15/15) with peripheral vascular disease, depression, diabetes, and a left above-knee amputation, dependent on staff for toileting, bathing, lower body dressing, and transfers, was observed with the call light on and reported needing to be changed and wanting a drink. The resident stated that sometimes the call light worked and sometimes it did not, and that staff would turn off the light, say they would return, and then not come back, sometimes resulting in waits longer than 30 minutes. Surveyors observed the call light above this resident’s door visible from the nurse’s station, with staff present in and around the area and using a nearby breakroom, while the call light remained unanswered. Housekeeping entered a nearby room first, and later a staff member entered the resident’s room, turned off the light, then went into the breakroom. The resident subsequently received a drink but had not been changed. A further cognitively intact resident (BIMS 15/15) with anxiety disorder, heart failure, need for assistance with personal care, respiratory failure, and dependence on supplemental O2, dependent on staff for toileting, lower body dressing, mobility, and transfers, was observed with the call light on and reported that while it had not been on long at that moment, call light response times could be as long as an hour. Resident council minutes over several months documented repeated concerns that nursing call light response times were longer than normal or taking longer, with ongoing reports that call lights were not being answered timely. The ADON stated that call lights should be answered as soon as possible, within about 5 to 10 minutes, and that if a need was not met, the call light should remain on. Facility policy stated that call lights would be placed within residents’ reach and answered in a timely manner, and that staff should identify the location and answer promptly, turning off the light only if able to meet the resident’s request. Despite this, surveyor observations, resident interviews, and council notes showed ongoing delays, nonfunctioning or improperly connected call lights, and staff turning off call lights without meeting residents’ needs.
Failure to Follow Oxygen Orders and Proper Nebulizer Equipment Handling
Penalty
Summary
The deficiency involves failures in safe and appropriate respiratory care, including improper oxygen administration and nebulizer equipment handling for multiple residents. For one resident with COPD receiving scheduled Ipratropium-Albuterol nebulizer treatments four times daily, surveyors observed the nebulizer mask and tubing stored in a clear bag with the medicine chamber still wet and containing liquid drops, contrary to the facility’s nebulizer policy that requires rinsing and allowing the nebulizer to air-dry. The medication administration record showed a morning dose documented as given and an early afternoon dose documented as not given on the day of observation. Another resident, cognitively intact and dependent on staff for several ADLs, was found lying in bed without oxygen in place; the nasal cannula and tubing were positioned by the wall and out of reach. The resident stated she was supposed to use oxygen all the time and reported that a CNA had assisted with changing her shirt, during which the oxygen was removed and not replaced for about an hour. When staff were alerted, the resident’s oxygen saturation was measured at 87–88% before oxygen was reapplied. A third cognitively intact resident, dependent on supplemental oxygen, was observed receiving oxygen at 4 L/min via concentrator and nasal cannula. Review of the medical record with the ADON showed a physician’s order for oxygen at 2 L/min, indicating the oxygen flow being delivered did not match the provider’s order. The facility’s oxygen policy did not include directives on following provider orders or monitoring liters of oxygen to be used.
Failure to Timely Transfer and Monitor Resident with Acute Change in Condition
Penalty
Summary
A resident with a complex medical history, including gram-negative sepsis, heart failure, and dependence on supplemental oxygen, experienced an acute change in condition that was not promptly recognized or addressed by facility staff. The resident became unresponsive, diaphoretic, and exhibited labored breathing with a high fever and abnormal urine characteristics. Despite these significant changes, there was a delay in transferring the resident to the hospital, and staff failed to provide timely and thorough assessments or interventions during the acute episode. Documentation and interviews revealed that staff did not consistently monitor or document the resident's vital signs or Foley catheter status. The care plan and Kardex lacked specific interventions for ongoing assessment and monitoring of the Foley catheter, and staff were unclear on how to track urine output for residents with catheters. CNA and nursing documentation indicated that only one set of vital signs was recorded during the critical period, and there was no evidence of further nursing care or assessment until EMS arrived. Upon EMS arrival, the resident was found to be in severe distress, with a temperature of 104.1°F, unresponsiveness, and significant respiratory compromise, requiring intubation shortly after arrival at the emergency room. Interviews with facility leadership and staff highlighted gaps in communication, documentation, and escalation of care. Concerns raised by the resident's family regarding decreased mobility and responsiveness were not thoroughly assessed or communicated to the appropriate staff. The lack of clear protocols for monitoring residents with Foley catheters and the absence of timely nursing interventions contributed to the delay in recognizing the severity of the resident's condition and transferring him to the hospital.
Failure to Ensure Dignified Care and Timely Call Light Response
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were treated with dignity and respect, specifically regarding timely call light response, food palatability, and accessibility of call lights. During a Resident Council meeting, nine residents unanimously reported prolonged call light response times, often averaging 30 minutes or more. Residents described instances where staff would turn off call lights and promise to return but failed to do so, leaving residents waiting for assistance with activities of daily living (ADLs). Staff were also observed talking loudly, using cell phones, and gathering at the nurse's station while residents waited for help. Some residents reported being left soiled and wet for extended periods, and staff sometimes gave false reasons for delays, such as claiming equipment was unavailable when it was not. Residents also expressed dissatisfaction with the quality and variety of food, noting repetitive menus and unappetizing meals. They reported that alternative meal options often consisted of leftovers from previous meals, and that bedtime snacks were either not provided or only available if residents went to the nurse's station themselves. These concerns were consistently raised in Resident Council meetings from December to May, but meeting minutes showed a lack of follow-up or resolution. The March meeting was not held due to a COVID-19 outbreak, and there was no documentation of attempts to address the issues or communicate with the Resident Council president. Specific resident observations further supported these findings. One resident, who was cognitively intact and had a history of chronic embolism, muscle weakness, and dysphagia, reported average wait times of over 30 minutes for call light response and noted that staff sometimes did not return after turning off the call light. Another resident was found unable to locate his call light, which was on the floor and out of reach, despite housekeeping staff entering and exiting the room without noticing. A nurse aide eventually found and repositioned the call light. These events demonstrate the facility's failure to maintain an environment that promotes dignity, timely care, and respect for residents' rights.
Failure to Resolve Resident Grievances and Inform Residents of Grievance Process
Penalty
Summary
The facility failed to provide prompt efforts to resolve multiple grievances raised by a group of nine residents, as required by federal regulations. During a Resident Council meeting, residents reported ongoing issues such as prolonged call light response times, dissatisfaction with food palatability and variety, lack of bedtime snack distribution, limited group activities due to transportation issues, and concerns about staff availability and attitude. Residents expressed that their complaints were not being addressed or followed up on, and that they were not informed about the grievance process or the existence of a grievance form. When the grievance form was presented during the meeting, several residents indicated it was their first time seeing it and were unaware of how to file grievances or to whom they should report their concerns. Review of Resident Council meeting minutes from December through May revealed a lack of documentation regarding the resolution or follow-up of previously raised concerns. Old business sections in the minutes were often left empty, and unresolved issues were not consistently carried over or addressed in subsequent meetings. The March meeting minutes were missing, and the Administrator explained that the meeting was not held due to a COVID-19 outbreak, but there was no documentation of postponement or attempts to resolve outstanding issues. The Administrator also indicated a lack of awareness regarding her ability to attend council meetings to address concerns directly. Specific grievances included the absence of field trips since the facility sold its bus, repetitive and unappealing food menus, staff failing to provide or distribute bedtime snacks, and staff not responding promptly to call lights or making excuses about unavailable equipment. Residents also reported that staff sometimes turned off call lights without fulfilling requests and were observed socializing or using cell phones instead of attending to residents' needs. One resident with diabetes was unaware of the availability of bedtime snacks and had not received them. The facility's failure to inform residents about the grievance process and to document or resolve ongoing concerns resulted in unresolved grievances and resident frustration.
Failure to Consistently Provide and Distribute Bedtime Snacks
Penalty
Summary
The facility failed to ensure that a substantial bedtime (HS) snack was consistently offered and appropriately distributed to residents, as required by federal regulations. During a Resident Council meeting, nine residents reported that HS snacks were not provided or were only available if residents went to the nurse's station themselves. This practice excluded residents who were unable to reach the nurse's station or advocate for themselves. One resident with diabetes reported never receiving an HS snack and was unaware that such snacks were available. The issue was raised during multiple Resident Council meetings, with concerns about snacks not being passed and lack of follow-up on these issues. A review of Resident Council meeting minutes from December to May revealed missing documentation for March and no evidence of follow-up or resolution of previously discussed concerns. The Administrator was unaware of the ongoing issues and had not attended council meetings or documented the postponement of the March meeting due to a COVID-19 outbreak. There was no indication that the facility addressed or resolved the concerns raised by residents regarding the distribution of HS snacks.
Multiple Lapses in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen to maintain sanitary conditions and adhere to food safety standards. Outdated food items were found in both the refrigerator and freezer, including pre-made sandwiches and cooked dishes that were past their use-by dates, some of which were unlabeled or not properly covered. The walk-in refrigerator was found at 40°F, and the freezer was observed at temperatures above the required 0°F, with the CDM unaware of the improper readings. Temperature logs for the refrigerator and freezer were incomplete, with some entries filled in before the shift began, and key identifying information left blank. Additionally, three dented cans were found mixed with undamaged cans, and two ice scoopers were not stored appropriately, with one left uncovered on top of the ice machine. A spider and web were discovered on top of the grill during a hot tray observation, further indicating lapses in kitchen sanitation. The CDM acknowledged these issues during the survey and confirmed that staff should be checking food dates daily. Policies for temperature monitoring, leftover food, and kitchen sanitation were reviewed, and all findings were discussed with the Administrator. The deficiencies identified have the potential to affect all residents consuming food prepared by the facility.
Failure to Properly Document and Maintain Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that code status was properly assessed, documented, and accessible in the medical record for two residents reviewed for advance directives. For one resident admitted with a history of stroke, right-sided weakness, hypertension, anxiety, aphasia, and dysphagia, the electronic medical record indicated "Full Code" status on the face sheet and medication records, but there was no care plan for code status and no documented assessment of code status preferences in the "Documents" tab. The code status assessment form was only completed and signed by the social worker after the deficiency was identified, and not by the resident. Interviews with staff revealed that the code status assessment was missed during the admission process and that there was confusion regarding responsibility for completing the assessment. For another resident with cerebral infarction, dysphagia, diabetes, hemiplegia, hemiparesis, and vascular dementia, who was enrolled in hospice and had a legal guardian, the care plan indicated DNR and hospice services. However, the DNR order form in the medical record was not signed by a physician as required, and the previous DNR order had expired. The social worker confirmed that the DNR order was not current and that it was their responsibility to ensure the form was accurately completed and signed. Facility policy required annual review and physician signature for DNR orders, which was not followed in this case. The facility's own policy specified that advance directives and code status forms should be obtained, signed, and placed in the medical record upon admission, with annual review and re-signing as necessary. In both cases, the required documentation and signatures were either missing or incomplete, resulting in a lack of clear, accessible, and current information regarding the residents' code status and advance directives.
Failure to Administer Ordered Medications and Wound Treatments
Penalty
Summary
The facility failed to ensure that prescribed treatments and medications were administered as ordered for two residents. One resident with multiple comorbidities, including osteomyelitis, pressure ulcers, and morbid obesity, developed a facility-acquired pressure ulcer on the left lateral malleolus. The wound care clinic recommended a collagen/silver combination dressing for this wound, with instructions to change the dressing daily and a supply provided for 30 days. However, the facility was unable to consistently apply the recommended dressing due to a reported shortage of the product, and instead used a different dressing (calcium alginate with silver) that was not in accordance with the wound clinic's orders. Interviews with nursing staff revealed uncertainty about whether alternative suppliers or other corporate facilities were contacted to obtain the correct dressing, and documentation showed ongoing use of the non-recommended product. Another resident, admitted with a history of stroke, hypertension, and other conditions, did not receive her prescribed blood pressure medication, Nifedipine, for multiple days following admission. The medication was not available in the facility or from the backup pharmacy, and repeated documentation indicated ongoing communication with the pharmacy and the nurse practitioner about the unavailability. The resident expressed distress about not receiving her medication, which was ordered to be given four times daily. Despite care plan interventions specifying the need to administer medications as ordered and monitor for complications related to hypertension and recent intracranial hemorrhage, the medication was not administered as prescribed for an extended period. In both cases, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and physician recommendations. The failure to provide the ordered wound care treatment and to administer essential blood pressure medication as prescribed constituted a deficiency in the quality of care provided to these residents.
Failure to Revise Care Plans and Follow Dietary Orders for Nutrition and Hydration
Penalty
Summary
The facility failed to ensure that dietary care plans were revised for actual weight loss and did not follow dietary orders for two residents, resulting in the potential for continued weight loss. One resident, a 91-year-old with multiple diagnoses including major depressive disorder, congestive heart failure, and anxiety, experienced a 10.1% weight loss over six months. Despite a significant weight loss being identified, there was no care plan addressing actual weight loss, only a care plan for potential alterations in nutritional status, which had not been updated. The Registered Dietitian confirmed that a care plan for actual weight loss should have been in place and acknowledged that no additional interventions were implemented beyond updating preferences and adding the resident to weekly weights. Another resident, admitted with diagnoses including heart failure, COPD, and mild protein-calorie malnutrition, had physician orders for a regular diet with large or double protein portions. The resident reported not consistently receiving the ordered double portions of protein and expressed concern about the lack of protein options and the quality of alternatives provided. The care plan did not mention the need for additional protein, and the nutritional evaluation failed to address the extra protein requirement. The resident's albumin levels were low and declining, and there was a lack of documentation and follow-up regarding the resident's dietary concerns and lab results. Both cases demonstrate failures in care planning and implementation of dietary orders. The facility did not update care plans to reflect actual weight loss or ensure that dietary interventions matched physician orders and resident needs. There was also insufficient monitoring and documentation of residents' nutritional status and preferences, as well as a lack of communication between dietary staff and other care team members regarding residents' changing conditions and concerns.
Failure to Provide Timely Dental Services and Dietary Adjustments
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, contracture, and hemiplegia was not provided timely dental services for an ill-fitting lower partial denture. The resident reported being unable to wear the denture due to poor fit and discomfort since receiving it, which affected his ability to chew certain foods such as chicken and hamburgers. Despite repeated documentation in dental visit notes over several months that the denture did not fit and the resident was not wearing it, no effective adjustment or replacement was made for an extended period of approximately ten months. The resident remained on a regular diet despite his inability to chew certain foods, and staff were aware of his difficulties. The registered dietitian was not directly informed of the resident's issues with the denture or eating, and only considered a diet change after being specifically asked. Dental records indicated ongoing problems with the denture, requests for adjustments, and pending x-rays, but there was no evidence of follow-up or resolution after the x-rays were completed. The unit manager confirmed that the resident should have been referred for further dental evaluation and dietary review much earlier. Facility policy required prompt referral for dental services within three days of lost or damaged dentures and documentation to ensure adequate nutrition if delays occurred. However, the resident's ongoing inability to use the denture and lack of timely intervention or dietary adjustment demonstrated a failure to meet these requirements. The deficiency was substantiated by interviews, record reviews, and direct observations of the resident's continued difficulty eating and lack of appropriate dental or dietary support.
Deficient Emergency Preparedness Policies and Procedures
Penalty
Summary
The facility failed to develop and implement emergency preparedness policies and procedures in accordance with regulatory requirements. Specifically, the emergency plan, risk assessment, and communication plan were not fully integrated into the facility's policies and procedures, and the required annual review and update of these documents was not completed. During record review, it was found that the policy for emergency situations involving electrical power outages directed staff to use an 'emergency kit' cart located in the 500 Hall. However, field verification revealed that there was no emergency kit cart in the 500 wing, as it had been moved to the 600 service hall without updating the policy or informing staff of the new location. Additionally, the facility's severe weather policy stated that staff would monitor a weather radio located at the main nurse station. Upon field verification, it was discovered that there was no weather radio at the main nurse station, contrary to what the policy indicated. These discrepancies were confirmed through an interview with the maintenance director at the time of record review. The lack of alignment between the facility's written policies and the actual resources and equipment available could affect all occupants in the event of an emergency.
Failure to Provide Functional Emergency Lighting
Penalty
Summary
On June 24, 2025, observations revealed that the facility failed to provide automatic emergency lighting in accordance with regulatory requirements. Specifically, the battery back-up emergency lighting over the transfer switches did not illuminate when tested, which would result in the area being left in darkness if the transfer switches failed to transfer power during a power loss. Additionally, the battery back-up light in the activities area above the doors did not illuminate when the test button was pressed, indicating that this area would also be left without emergency lighting during a power outage. These deficiencies were confirmed through interviews with the maintenance director at the time of observation.
Sprinkler System Maintenance Deficiency
Penalty
Summary
During an inspection, it was observed that the sprinkler escutcheon ring in the main office paper supply closet had slid down around the sprinkler head. This condition prevents the sprinkler from functioning as designed in the event of a fire. The issue was identified through direct observation and confirmed in an interview with the maintenance director at the time of the inspection. The facility failed to provide proper maintenance and testing of the sprinkler system as required by NFPA 25, resulting in a deficiency that could affect all occupants in the event of a fire.
Incomplete Annual Fire Door Inspections
Penalty
Summary
The facility failed to conduct a complete annual inspection and testing of all rated swinging fire doors as required by NFPA 101 and NFPA 80 standards. Record review on June 24, 2025, revealed that the inspection only included the seven sets of cross corridor rated fire doors and did not encompass all other rated doors, such as those for storage rooms, soiled utility rooms, and other tagged rated fire doors. This incomplete inspection was confirmed during an interview with the maintenance director at the time of record review.
Deficient Emergency Power System Maintenance and Documentation
Penalty
Summary
The facility failed to ensure that its generators and associated emergency power systems were maintained and tested in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 standards. During an observation, it was found that the automatic transfer switch number 2 for the equipment branch was not functioning, as indicated by the absence of display and indicator lights. The maintenance director confirmed that this issue had persisted since February or March, and that the generator company had not yet responded to address the malfunction. Despite the malfunction, the facility continued to have lights and power during outages, but the non-functioning transfer switch could limit available resources during a power loss. Additionally, a review of facility records revealed that there was no documentation available to verify that the back-up emergency generator had been serviced annually or that the required annual load bank test had been conducted. The maintenance director stated that the generator company had recently visited but had not yet provided any paperwork. The lack of documentation means that the facility could be unaware of potential generator issues, which may result in generator failure during a power outage. These findings were confirmed through interviews with the maintenance director at the time of observation and record review.
Obstructed and Inaccessible Emergency Exits Identified
Penalty
Summary
Surveyors observed that the facility failed to maintain clear and accessible means of egress as required by code. Specifically, the Human Resources office exterior door was found sealed shut and could not be opened, preventing its use in emergencies. Additionally, an excessive number of dialysis infusion transport chairs were stored in the emergency egress corridor outside the dialysis treatment room for several hours, with no dedicated space available to relocate them during an evacuation. Furthermore, the west emergency exit door from the main dining room was stuck closed and required excessive force to open, impeding emergency evacuation from that area. These deficiencies were confirmed through interviews with the maintenance director at the time of observation.
Exit Signs Not Illuminated on Emergency Power
Penalty
Summary
During an inspection, it was observed that exit signs in the older section of the facility did not remain illuminated when the battery back-up test button was pressed. This indicated that the exit signs were not transferring from regular power to emergency battery power as required. The maintenance director, when interviewed, believed that the signs were functioning properly, but the test demonstrated otherwise. These findings were confirmed through direct observation and interview with the maintenance director at the time of the inspection. The deficiency was noted to potentially affect 50 occupants in the event of a power loss, as the exit signs would not be illuminated during an outage. No specific residents or their medical conditions were mentioned in the report.
Deficient Fire Barrier Protection in Hazardous Area
Penalty
Summary
A deficiency was identified when, during an observation on June 24, 2025, the door to the soiled utility rated room in the 600 hall was found not to latch when closed. This door is required to be self-closing or automatic-closing and to latch in order to maintain the integrity of the fire barrier, as specified by regulatory requirements for hazardous area enclosures. The failure of the door to latch could allow smoke, heat, fire, or biohazard to escape the rated space and enter the emergency egress corridor. The findings were confirmed through an interview with the maintenance director at the time of observation. No specific information about the medical history or condition of the affected occupants was provided in the report.
Failure of Corridor Fire Doors to Fully Close Due to Faulty Door Arranger
Penalty
Summary
Surveyors observed that the double rated fire corridor doors located outside of resident room 210 did not fully close due to a failing door arranger. This deficiency was identified during an inspection on June 24, 2025, at approximately 12:15 PM. The inability of the doors to close completely compromises their function to resist the passage of smoke, as required by NFPA 19.3.6.3. The observation was confirmed through an interview with the maintenance director at the time of the inspection. This issue affects the doors protecting corridor openings, which are critical for preventing the transfer of smoke, heat, and fire between compartments. The deficiency could potentially impact 50 occupants in the event of a fire, as the compromised doors would allow smoke and fire to move from one compartment to another. No specific details about individual residents' medical histories or conditions at the time of the deficiency were provided in the report.
Failure to Timely Reorder Pain Medication Results in Resident Missing Fentanyl Patch
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident who required a Fentanyl transdermal patch for pain control. The resident, who was cognitively intact and able to communicate her needs, experienced a lapse in her pain management regimen when her Fentanyl patch fell off and there was no replacement available. Documentation shows that after the patch was applied, the resident was due for a new patch, but due to a lack of available patches and a delay in obtaining a new prescription, she went without her pain patch for three days. During this period, the resident reported increased pain and expressed frustration with the lack of communication from staff regarding the situation. The clinical record and medication administration records confirm that the facility did not have a valid prescription to refill the Fentanyl patches, and attempts by the pharmacy to contact the provider for a new script were unsuccessful. The facility's process for reordering controlled substances was not effectively followed, resulting in a gap in pain management. The resident's daughter also raised concerns about the potential for withdrawal due to the missed medication. There was no documentation of timely communication with the provider or pharmacy to resolve the issue before the resident missed multiple doses.
Deficiencies in IV Medication Management
Penalty
Summary
The facility failed to properly assess and monitor intravenous medication therapy for two residents, leading to deficiencies in the administration of Vancomycin. Resident #702 was admitted with several serious conditions, including necrotizing fasciitis and stage 3 kidney disease, and was prescribed Vancomycin to be dosed by the pharmacy. However, there was a lack of communication between the facility and the pharmacy, resulting in the pharmacy not receiving the order to dose until nearly four weeks after the initiation of the antibiotic. During this period, Resident #702's Vancomycin levels were consistently subtherapeutic, and there was no documentation that the facility contacted the pharmacy regarding these levels until the practitioner intervened. Resident #703, who had acute kidney failure and other serious conditions, was also prescribed Vancomycin. Despite elevated Vancomycin levels being reported, the facility failed to communicate these results to the pharmacy in a timely manner. As a result, Resident #703 received two additional doses of Vancomycin after the elevated levels were identified. The facility staff contacted the pharmacy 24 hours after receiving the lab results, at which point the pharmacy ordered the antibiotic to be held due to the elevated levels. Interviews with facility staff, including the DON and a nurse, revealed a lack of clarity and consistency in the procedures for managing Vancomycin dosing and communication with the pharmacy. The facility did not have a policy for intravenous medications or a specific procedure for when residents are prescribed Vancomycin. Additionally, there was no standard practice for documenting the communication of lab results to the pharmacy, contributing to the oversight in dosing management for both residents.
Failure to Assess and Document Wounds
Penalty
Summary
The facility failed to ensure proper wound assessment, monitoring, and intervention for a resident, resulting in the development of wounds on the resident's left foot great toe, left foot third toe, and right foot third toe. The resident, who had a history of chronic kidney disease, diabetes, and other health issues, was observed with necrotic and abraded areas on her toes. Despite an orthopedic consult identifying a wound on the left great toe on 8/29/2024, there was no corresponding documentation or physician orders in the resident's medical records. The facility's Wound Nurse acknowledged that the consult was missed, and an assessment was only initiated on 9/16/2024. The facility's care plans and policies required regular skin assessments and documentation of any abnormalities, but these were not followed. The resident's care plan included interventions for monitoring skin integrity and blood sugar levels, yet the wounds were not identified during routine assessments. The Director of Nursing confirmed that the wounds should have been documented and assessed, but they were not. The facility's policies emphasized the importance of identifying and documenting wounds and changes in resident status, which were not adhered to in this case.
Failure to Update Catheter Status and Documentation
Penalty
Summary
The facility failed to properly manage the indwelling urinary catheter for a resident, resulting in staff being unaware of the resident's catheter status. The resident, who had full cognitive abilities and required some assistance with care, was admitted with multiple diagnoses including neuromuscular dysfunction of the bladder. The Minimum Data Set (MDS) assessment indicated the presence of an indwelling urinary catheter. Despite the catheter being removed on a specific date, the orders for the catheter were not discontinued, and staff continued to document the presence and care of the catheter. The facility's records showed that after the catheter was removed, there were multiple entries indicating the resident still had an indwelling catheter, and catheter care was documented as performed numerous times. The care plans did not reflect the removal of the catheter, and the facility's policy on catheter care did not address discontinuation or removal. Interviews with the Infection Preventionist and the Director of Nursing confirmed the resident no longer had a catheter, yet the orders and documentation inaccurately reflected otherwise.
Sanitation and Equipment Maintenance Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment and ensure that equipment and plumbing were in good repair, which increased the risk of foodborne illness for all residents consuming food from the kitchen. Observations revealed white mold-like accumulation on two wire racks in the walk-in cooler, indicating a lack of cleanliness in food storage areas. Additionally, the steamer on the cookline was leaking water onto clean pitchers stored below, and the chef was unaware that the steamer should not be leaking, suggesting a lack of awareness and maintenance of kitchen equipment. Further issues included a backflow prevention device at the dish machine that was covered with a cloth and leaking water, with scale build-up from hard water, indicating improper maintenance. An opened jug of soy sauce was found unrefrigerated in the dry storage room, contrary to the manufacturer's instructions, showing a lack of adherence to food storage guidelines. The walk-in freezer door gasket was damaged with excessive ice build-up, and staff attempts to remove the ice were damaging the gasket further. Additionally, a spray bottle near the kitchen entrance was not labeled to identify its contents, posing a risk of contamination from unidentified toxic materials.
Failure to Ensure Accurate Advance Directives
Penalty
Summary
The facility failed to ensure accurate advance directive information for two residents, leading to potential non-compliance with residents' medical care preferences. Resident #182 was admitted with multiple diagnoses, including severe cognitive impairment. Despite having a physician's order for Do Not Resuscitate (DNR), there was no declaration of incompetence in the medical record, which is required to activate a Durable Power of Attorney (DPOA). The Social Worker Supervisor confirmed the absence of the necessary documentation and acknowledged that the DNR order was incorrect without a proper declaration of incompetence. Resident #88, who was cognitively intact, had an advance directive indicating a DNR status that was not witnessed by two people as required. The social worker responsible for ensuring the documentation was complete could not explain why the necessary signatures were missing. During the survey, it was found that the advance directive was filled out and scanned into the medical record, but the timing of this action was unclear. The facility's policy requires a determination of a resident's cognitive level by two physicians or a physician and a psychologist before a DPOA can be activated. This process was not followed for Resident #182, and the advance directive for Resident #88 lacked the required witness signatures. These deficiencies highlight the facility's failure to adhere to its own policies and state requirements for advance directives, potentially compromising residents' rights to have their medical care preferences respected.
Failure to Assess and Document Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints without proper assessment and documentation. A resident was observed with a half lap tray attached to their wheelchair on multiple occasions. However, there was no initial assessment found in the resident's electronic medical record to determine if the lap tray was a restraint or an enabler. An assessment was only completed during the survey, which indicated the tray was for positioning, support, and comfort. Despite this, the care plan was not updated to reflect the assessment findings. The facility's policy required a physical device evaluation before using any device, a current signed restraint consent, and a current order specifying the type of restraint, when to use it, the medical symptom for its use, and a release/exercise statement. None of these requirements were met for the resident in question. The Director of Nursing confirmed that an evaluation should have been performed prior to the use of the device and that the care plan should have been updated accordingly.
Deficiencies in Care Plan Implementation and Documentation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in their care. For one resident, the care plan did not specify the side effects of the medications Seroquel and Zoloft, which were prescribed for mood disorder and depression, respectively. The care plan only included generic side effects and did not mention the specific medications the resident was receiving. This lack of specificity in the care plan could hinder staff's ability to monitor and manage potential adverse reactions effectively. Another resident's care plan was not updated to reflect a new order for Zoloft, and it lacked specific interventions related to the medication's use and side effects. Additionally, this resident was observed with a half lap tray attached to their wheelchair, but there was no documentation specifying the medical reason for its use. A physical restraint assessment was not found in the resident's electronic medical record until it was completed during the survey. The care plan did not indicate why the lap tray was necessary, and the Director of Nursing stated that an evaluation should have been performed before using the device, with the care plan updated accordingly.
Deficiencies in ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide appropriate care for Activities of Daily Living (ADL) for three residents, resulting in not achieving and/or maintaining their highest practicable well-being. Resident #91, who is severely cognitively impaired and dependent on staff for personal care, was found with long, dirty nails and dry, flaking skin. Despite documentation indicating care was provided, interviews with the resident's daughter revealed that the resident was not receiving adequate hygiene care, such as proper foot cleaning and nail trimming. Resident #80, who is cognitively intact but dependent on staff for personal care, reported not receiving showers as preferred and was observed with greasy hair and uneven shaving. The resident expressed dissatisfaction with the care provided, stating that only partial bed baths were given instead of full showers. Documentation did not specify whether the resident received a shower or a bed bath, and the shower log did not reflect the resident's preferences or the care provided. Resident #32, who is cognitively intact and has multiple medical conditions, was observed with long, dirty fingernails and reported not receiving oral care or showers as scheduled. Despite being marked as having received a bed bath or shower, the resident stated otherwise, and a CNA confirmed that the resident did not receive the care documented. The resident expressed a desire for reminders of shower days and reported not receiving scheduled showers.
Failure to Maintain and Remove PICC Line as Ordered
Penalty
Summary
The facility failed to perform dressing changes as ordered and did not follow the physician's orders for the removal of a peripherally inserted central catheter (PICC) for a resident, resulting in potential risks. The resident, who was admitted with diagnoses including neurogenic bladder and sepsis, was observed with a PICC line in his left upper arm that had not been maintained according to the physician's orders. The dressing on the PICC line was dirty, stained, and peeling, with no date indicating when it was last changed. The resident, who was knowledgeable about PICC line maintenance, reported that it had been over a week since the dressing was changed and that his concerns were dismissed by the staff. The treatment administration record showed a physician's order to change the PICC line dressing every seven days, which was last marked as completed on 5/25/24. Additionally, there was an order for the removal of the PICC line, which was marked as completed, although the line was still in place. Interviews with the LPN and the ADON revealed a lack of awareness and oversight regarding the resident's PICC line status. The ADON confirmed that the PICC line should have been removed and acknowledged that the completion of the order led to the cessation of required dressing changes and flushes, indicating a breakdown in communication and adherence to care protocols.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement appropriate interventions to promote pressure ulcer healing and prevent the development of new pressure ulcers for Resident #37 and Resident #91. Resident #37 was observed with his feet pressed against a Medi-[NAME] case on his bed, which contributed to the development of a pressure ulcer on his left toe. Despite having a care plan that included floating heels and using soft heel lift boots, these interventions were not consistently implemented, as evidenced by observations of Resident #37's heels not being floated and the green foam boot not being used. Additionally, the maintenance team was not promptly informed about the need for a new bed frame to prevent further injury. Resident #91, who was severely cognitively impaired, was found with a dressing on his left heel that had not been changed according to the prescribed schedule. The care plan for Resident #91 included floating heels and using a pressure reduction mattress, but these measures were not observed during the survey. The dressing on the left heel was dated several days prior, indicating a lapse in wound care management. Furthermore, the sacral pressure ulcer care was not adequately documented, and the necessary repositioning and support to prevent further skin breakdown were not consistently provided. The facility's staff, including the wound care nurse and maintenance personnel, demonstrated a lack of coordination and timely response to the residents' needs. The wound care nurse was unaware of the purpose of the Medi-[NAME] and delayed notifying maintenance about the bed frame issue. Additionally, the documentation of wound care interventions and refusals was incomplete, contributing to the inadequate management of pressure ulcers for both residents. These deficiencies highlight a failure in the facility's processes to ensure proper pressure ulcer prevention and care.
Failure to Implement Behavioral Health Interventions for a Resident
Penalty
Summary
The facility failed to provide necessary behavioral health care interventions for a resident with a history of depression and anxiety. The resident, who was cognitively intact and had multiple diagnoses including major depressive disorder and bipolar disorder, reported feelings of loneliness and depression. Despite previous psychology notes recommending encouragement of socialization and participation in meaningful activities, the resident was observed in a room with closed blinds, no reading materials, and without a displayed activities calendar. The resident expressed a desire to regain strength to use a power wheelchair and mentioned past suicidal remarks, although there was no current desire to act on them. The care plan for the resident included interventions such as offering materials for individual activities and encouraging participation in group activities. However, the resident had not received any 1:1 visits in the past 30 days, which was a part of the recommended interventions. The Activities Director confirmed that the resident was not on the 1:1 visit list, despite acknowledging that the resident would benefit from such activities. This oversight resulted in the resident not receiving the necessary behavioral health care and services, potentially exacerbating their mental health issues.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 20.69% due to six medication errors observed out of 29 opportunities. For Resident #186, a Registered Nurse (RN) administered insulin Lispro based on a blood glucometer reading taken after the resident had consumed breakfast, contrary to the physician's order to obtain the reading before meals. Additionally, the Fenofibrate Oral Tablet was not administered at the scheduled time of 09:00 a.m. due to its unavailability, and there was no documentation of physician notification for the delay. For Resident #64, a Licensed Practical Nurse (LPN) left a medication cup containing four pills unattended on the resident's over-bed table while the resident was asleep. The LPN acknowledged that leaving medications unattended was not standard practice. These actions and inactions contributed to the facility's failure to adhere to proper medication administration protocols, as observed during the survey.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to prevent a significant medication error for a resident who was not administered a prescribed medication, leading to the potential for a worsening infection. The resident, who had a history of cerebral infarction, gastrostomy status, and heart failure, was admitted with a diagnosis of osteomyelitis in the right heel. The resident was prescribed intravenous Vancomycin and Cefepime for the infection. However, the Medication Administration Summary for April and May showed several instances where Vancomycin doses were either held or not given without any explanation documented in the medical record. The Assistant Director of Nursing, who temporarily assumed the role of Infection Control Nurse, acknowledged the issue of missing Vancomycin doses. The ADON indicated that the nursing staff was educated on using the appropriate code when charting in the Medication Administration Record. Some missed doses were attributed to delays in receiving Vancomycin trough results, which were required by the pharmacy before sending additional doses. The medical provider was notified of the missed doses, and increased monitoring for infection was implemented.
Food Temperature Deficiency
Penalty
Summary
The facility failed to serve food at the preferred temperature for a resident, resulting in dissatisfaction during meals. The resident, who was admitted with multiple diagnoses including insomnia, depression, heart failure, and anxiety, was observed to be cognitively intact with a BIMS score of 15 out of 15. During an interview, the resident expressed dissatisfaction with the food, stating it was frequently cold. On a specific observation, the food cart arrived at the resident's unit, and the resident's meal was delivered. The Certified Dietary Manager (CDM) was present and took the temperatures of the food items on the resident's tray. The fish, cauliflower, and potatoes were found to be below the required temperature of 140 degrees Fahrenheit, while the apple pie was at an appropriate temperature. The CDM acknowledged the temperature issue and took the tray back to the kitchen for reheating.
Failure to Coordinate Hospice Services for Resident
Penalty
Summary
The facility failed to coordinate hospice services for a resident, resulting in the potential for care not being provided and residents not being fully informed of hospice services. The resident, who was admitted with multiple diagnoses including COPD, dysphagia, and prostate cancer, was receiving hospice services as indicated in the medical record. However, the resident was unable to explain the schedule or disciplines of the hospice services, and no hospice calendar was observed in the resident's room. The plan of care did not specify the hospice disciplines or the frequency of care, and the Kardex used by CNAs did not indicate that the resident was on hospice services. Interviews with facility staff revealed confusion and lack of clarity regarding the hospice services provided. A CNA referred to a notebook at the nurse's station, which contained two different weekly calendars without dates, and was unable to determine which was accurate. Another CNA could not find hospice information in the resident's Kardex. The Director of Nursing and Social Work Technician also could not confirm the correct hospice calendar, and it was revealed that the resident had not received a copy of the hospice calendar. The facility's policy required a plan of care reflecting hospice participation and ensuring staff awareness of their responsibilities, which was not adhered to in this case.
Failure in Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to implement and operationalize policies and procedures for pressure ulcer prevention and management for two residents, resulting in the development and worsening of facility-acquired pressure ulcers. Resident #704, who was admitted with multiple diagnoses including diabetes, heart disease, and hemiplegia, developed a Stage II pressure ulcer on their left buttocks, which worsened to a Stage III ulcer. The facility's records indicated a lack of consistent and appropriate interventions, such as the absence of a specialty mattress and inadequate documentation of turning and repositioning, which contributed to the deterioration of the resident's condition. Resident #710, admitted with heart failure and decreased mobility, developed a Stage III pressure ulcer on their left heel. Despite being at risk for pressure ulcer development, the resident's care plan lacked specific interventions to prevent such injuries. The facility staff, including a CNA and a wound care RN, were unaware of the resident's pressure ulcer and the necessary preventive measures, such as floating heels or using heel boots. The resident's care plan and Visual/Bedside Kardex did not reflect the resident's actual needs, leading to inadequate care and the development of the pressure ulcer. The facility's policy on skin management was not effectively implemented, as evidenced by the lack of appropriate preventative measures and documentation for residents at risk of skin compromise. The facility's failure to provide adequate care and monitoring for residents with pressure ulcers or those at risk resulted in unnecessary pain and a decline in the residents' overall health status. The report highlights significant deficiencies in the facility's pressure ulcer prevention and management practices, as observed by surveyors.
Deficiency in Emergency Medical Equipment Management
Penalty
Summary
The facility failed to ensure the proper monitoring and accessibility of emergency medical equipment and supplies, leading to expired and unsanitary items in two emergency medical response carts. During an observation, it was found that the crash cart in the central area of the facility had a lock number that did not match the documented log, indicating it had been opened and not properly restocked. Expired medications and supplies, such as an Epinephrine Auto Injector and various IV catheters, were found in the cart. Additionally, the Automated External Defibrillator (AED) was visibly soiled, and the Director of Nursing (DON) confirmed it needed cleaning. A second emergency cart on the 600-hall was also inspected and found to contain expired items, including oral glucose gel and sterile water containers. The suction tubing was improperly connected and uncovered. The cart lacked essential items like an Epinephrine pen and glucometer control/testing solution. The DON acknowledged the discrepancies and the difficulty in ordering AED pads, which resulted in only one set being available. The facility's policy on medical emergency management was reviewed, revealing that supplies should be regularly checked and maintained. However, the DON was unable to provide a consistent list of required items for the carts, and the facility's policy on glucometer testing did not include information on running controls. This lack of consistency and oversight in maintaining emergency supplies could lead to delays in care during medical emergencies.
Failure to Prevent and Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure an environment free of abuse by a staff member for three residents, resulting in a lack of administrative oversight to identify and monitor for increased risk of abuse by staff, and prevent abuse. Resident #709 experienced verbal abuse and neglect, while Resident #702 and Resident #711 experienced physical abuse, including intimidation. The facility did not adequately investigate or document the allegations, nor did they suspend the accused staff member, CNA G, following the allegations. Resident #709 reported to a Hospice RN that CNA G had attempted to touch them sexually, and they did not want CNA G to care for them. The resident also reported being neglected, as they were left covered in stool despite asking for help. The Hospice RN confirmed the resident's cognitive status as occasionally confused but able to verbalize needs. The facility's investigation did not include interviews with other staff or residents, and CNA G continued to work without suspension. Resident #702 reported being pushed down on their bed and having their shirt grabbed by CNA G, which brought back traumatic memories of past abuse. Resident #711 reported being grabbed by the neck by CNA G, which they perceived as intimidation. Both residents indicated that CNA G was moved to a different hall but continued to work in the facility. The facility's documentation and investigation into these incidents were inadequate, with no evidence of a thorough investigation or reporting to the state agency.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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