Woodward Hills Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomfield Hills, Michigan.
- Location
- 39312 Woodward Ave, Bloomfield Hills, Michigan 48304
- CMS Provider Number
- 235556
- Inspections on file
- 29
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Woodward Hills Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident who required a two-person assist for ADLs was being changed by only one CNA, resulting in the resident rolling out of bed and sustaining a serious head injury. The CNA involved had a history of improper transfers with other residents, and required documentation for the incident was missing. The facility's fall protocol and transfer status policy were not followed.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely.
A resident admitted with hypokalemia and dependent on staff for all ADLs had concerns raised by their case manager, but the facility did not document, investigate, or resolve the grievance as required by policy. The social worker did not complete a grievance form, and the administrator could not provide any records of the grievance or its resolution.
Two residents with a history of conflict and behavioral issues were involved in a physical altercation after ongoing verbal threats and disagreements about room lighting. Despite staff awareness of escalating tensions and prior threats, no effective interventions or care plan updates were implemented, and there was a delay in reporting and documenting the incidents. The facility failed to protect residents from abuse and did not ensure proper communication or preventive measures.
A resident with moderate cognitive impairment was found by a family member to have an unexplained skin tear and bruising on the arm, with no documentation or investigation by facility staff. Required incident reporting, assessment, and notification procedures were not followed, and the injury was not addressed in the medical record or communicated to the responsible party.
Two residents experienced missed or delayed wound treatments, including omitted care for sacral, buttock, and heel wounds, and delays in identifying and treating a left heel pressure ulcer. Staff also failed to consistently complete and document required weekly skin assessments, with some assessments marked as done but lacking supporting documentation. Communication lapses and inconsistent adherence to wound care protocols contributed to these deficiencies.
A resident admitted with hypokalemia and dependent on staff for all ADLs did not receive an initial comprehensive visit from a physician as required. Instead, the first visit was completed by an NP, and there was no timely physician documentation or approval for the admission. The physician's order confirming agreement with care plans was signed after the resident had already left the facility.
A resident was not treated with dignity when staff failed to retrieve and deliver their personal hygiene wipes after a room transfer. Although a nurse documented the need and relayed the request, the DON confirmed that the nurse should have personally ensured the wipes were delivered, in accordance with the facility's resident rights policy.
A resident reported feeling unsafe and alleged verbal and physical abuse by a CNA, prompting the involvement of the DON and local police. Although the CNA was removed from duty and an internal investigation was conducted, the facility did not report the abuse allegation to the State Agency as required by policy, citing lack of substantiation.
A resident with paraplegia and multiple diagnoses, who required a two-person assist for bed mobility, was turned by a CNA without assistance, leading to the resident rolling out of bed and sustaining a skin tear. The CNA was unaware of the two-person requirement, and the care plan was not followed, resulting in an avoidable fall.
A resident with significant pain management needs did not receive prescribed oxycodone as ordered due to the facility running out of the medication. Despite the availability of oxycodone in the emergency supply, staff did not utilize it, resulting in a delay of approximately 12 hours between doses and the resident experiencing severe pain.
A resident with dementia and diabetes developed an unstageable pressure ulcer on the left heel due to wearing tight-fitting shoes in bed, leading to a sepsis infection. The facility failed to document attempts to remove the shoes or the resident's refusal, and did not implement care plan interventions such as floating heels or providing heel boots. Interviews with staff confirmed the lack of prior intervention, contributing to the development of the ulcer.
A facility failed to provide adequate supervision and safe transfer assistance, resulting in multiple falls and injuries for residents with cognitive impairments and mobility issues. One resident suffered fractures due to a CNA not following the care plan for a two-person assist. Another resident, with a history of falls, was found without necessary Dycem on their wheelchair cushion, leading to a fall. A third resident, with severe cognitive impairment, was observed attempting to get out of bed without assistance, highlighting the facility's failure to implement effective interventions.
The facility failed to maintain sanitary conditions in the kitchen and pantry areas, with issues such as missing plastic edging on a cart, buildup on a coffee dispenser, and missing grout in the dish machine room. Additionally, microwaves were rusted, and fruit cups were uncovered during transport to resident rooms, violating FDA Food Code standards.
The facility failed to maintain comfortable room temperatures, with measurements in several rooms ranging from 60 to 69 degrees Fahrenheit, below the required 71-81 degrees. A resident in one room was observed cold, wrapped in a blanket and wearing a winter hat. The Maintenance Director acknowledged that temperatures are monitored but not recorded, violating the facility's policy.
A resident experienced frequent shortages of pain medication due to the facility's failure to accurately document and account for controlled substances. Discrepancies were found between the MAR and Proof of Use forms, with doses documented as administered without corresponding entries and unaccounted tablets. The facility's protocols for administering controlled substances were not followed, leading to inconsistencies in medication records.
A resident received duplicate doses of furosemide on three occasions due to active duplicate orders on the eMAR. The Consultant Pharmacist had recommended discontinuing one order, but both remained active, and the error was not communicated to a physician. The DON and AIT noted the error occurred after the resident's hospital readmission.
A resident on contact precautions for VRE was not properly isolated, as staff failed to display signage or provide PPE outside the room. The resident was observed interacting with others and moving around the facility, contrary to physician orders. The facility's infection control policy was not adhered to, as confirmed by interviews with the DON and AIT.
The facility failed to maintain resident dignity and respect, as evidenced by multiple incidents of inappropriate staff behavior and inadequate care. Residents reported rude interactions, lack of privacy, and insufficient assistance during personal care. The facility's policy on dignity was not adhered to, compromising resident well-being.
A resident with severe cognitive impairment and multiple mental health diagnoses did not receive a timely referral for a PASARR Level II evaluation. The facility's policy requires such evaluations to ensure appropriate placement and service determination, but there was no evidence of a completed evaluation or exemption request in the resident's record.
A facility failed to timely assess a facial bruise for a resident with impaired cognition, assuming it was from a previous fall without proper documentation. Additionally, two residents did not receive medications on time, with one experiencing pain due to the delay. The facility's policy required medications to be administered within a one-hour window, which was not adhered to. Furthermore, a resident had an undated dressing on their arm without a physician's order, contrary to facility policy.
The facility failed to ensure proper orders and monitoring for PICC line dressing changes for two residents. One resident, receiving antibiotics through a PICC line, was observed with a dressing that was not properly adhered. There was a gap in the orders for dressing changes, and existing orders lacked specific details. The AIT and DON acknowledged the oversight and the improper use of order templates.
A facility failed to follow up on the guardianship process for a resident deemed incompetent to make medical and financial decisions. Despite a competency evaluation and a plan for the resident's son to file for emergency guardianship, there was no evidence of follow-up by the Social Work Department. The former DON, now an AIT, confirmed the department's responsibility for this task.
The facility did not ensure that a resident's monthly drug regimen review by the consultant pharmacist was reviewed by the medication provider for recommendations. The resident, with chronic respiratory failure, chronic kidney disease, and type II diabetes, had irregularities noted by the pharmacist, but no documentation of these was found in the clinical record. The DON/AIT could not locate the necessary documentation in the electronic record during the survey.
A resident was not offered the 2024-2025 seasonal influenza vaccine at the start of the new flu season. The resident's immunization records showed no evidence of the vaccine being offered, and the Infection Control Preventionist confirmed this oversight. The facility's vaccination policy did not address offering the influenza vaccine at the beginning of the flu season.
A resident in a LTC facility did not receive timely follow-up dental services, despite expressing a desire for bottom dentures and having intact cognition. The resident's last documented dental evaluation was over a year ago, with no follow-up services recorded. Facility staff were unable to provide documentation of refusal or explain the lack of follow-up, contrary to the facility's dental services policy.
The facility failed to ensure skin assessments were documented, completed accurately, and timely for a resident with a history of Metabolic Encephalopathy, Cellulitis, and Sepsis. Despite physician orders and indications in the Treatment Administration Record, proper documentation in the Total Body Skin Evaluation was not completed, as confirmed by nursing staff and the DON.
Failure to Follow Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan and facility fall protocol, resulting in a serious injury. One resident, who was care planned as a two-person assist for activities of daily living (ADLs), was being changed by only one certified nursing assistant (CNA). During this process, the resident rolled out of bed, sustained a head injury, and required a higher level of care. The resident was later re-admitted with a diagnosis of traumatic subarachnoid hemorrhage, contusion of the left eye, and a history of falls. The incident report confirmed that the transfer was not performed according to the resident's required assistance level. Further review revealed that the CNA involved had previously dropped three different residents during improper transfers. The administrator acknowledged that the CNA had been educated on proper transfer procedures but failed to follow them. Additionally, required documentation related to the incident and accident reports was missing. The facility's policy mandates adherence to transfer status and completion of all necessary documentation, which was not followed in this case.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Address and Resolve Resident Grievance
Penalty
Summary
The facility failed to address and resolve concerns reported on behalf of a resident who was admitted with hypokalemia and required staff assistance with all Activities of Daily Living (ADLs). The resident's case manager raised concerns to the facility's social worker, who documented that appropriate parties were asked to follow up. However, there was no evidence that a formal grievance was filed or that the concerns were investigated and reported back to the complainant as required by the facility's grievance policy. The facility's grievance policy states that all grievances, whether oral or written, must be investigated and reported back to the grievant within fifteen days. Despite this, the administrator was unable to provide any documentation of grievances or concerns filed for the resident, and the social worker could not recall the specific concerns or provide additional documentation. No further explanation or documentation was provided by the end of the survey, indicating a failure to follow the established grievance process.
Failure to Prevent and Address Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse during two resident-to-resident incidents involving two cognitively intact residents with multiple medical diagnoses. One resident, who required maximal assistance with activities of daily living, was transferred into a shared room, which led to escalating tensions with their roommate. The roommate, who had a history of behavioral episodes and vision concerns, became increasingly agitated over disagreements about room lighting and personal space. Despite prior verbal threats and staff awareness of ongoing conflicts, no effective interventions were implemented to prevent further escalation. On the day of the incident, the agitated resident used a metal reacher to strike their roommate in the leg following a verbal altercation about the room lights. Staff responded immediately to the incident, separated the residents, and contacted law enforcement. The assaulted resident reported pain and minor bruising but was not found to have sustained injuries upon subsequent assessment. The aggressor admitted to the physical act and showed no remorse, expressing ongoing dissatisfaction with having a roommate. Prior to the physical altercation, staff and social work documentation indicated awareness of repeated verbal threats and behavioral issues, including the resident's calls to 911 and explicit statements about not wanting a roommate. Despite these warning signs, the facility did not update care plans or implement interventions to mitigate the risk of abuse. Additionally, there was a delay in reporting the verbal abuse to facility leadership, and the incident was not documented in the assaulted resident's medical record as expected. The facility's failure to act on known risks and to document and communicate incidents contributed to the deficiency.
Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate and follow up on an injury of unknown origin for one resident who was admitted for short-term skilled rehabilitation and nursing care. The resident, who had a history of atrial fibrillation, stroke, urinary tract infection, hearing loss, and dementia with moderate cognitive impairment, was found by a family member to have a bandage on their arm, which upon removal revealed bruises and a gash. The family member reported not being notified by the facility about how the injury occurred, and there was no documentation in the resident's medical record regarding the incident, treatment, or notification to the physician or responsible party. Review of the resident's electronic medical record and skin assessments showed no documentation of a skin tear or related injury on the arm prior to the family member's discovery. Subsequent skin assessments did note a healing skin tear, but there were no corresponding incident or accident reports, progress notes, or treatment orders. The facility administrator confirmed that there were no incident or accident reports or investigations related to the injury, and the unit manager, upon review, was unable to find any documentation or explanation for the injury in the medical record. Interviews with facility staff, including the unit manager and administrator, revealed that the expected process for investigating such injuries—completing a nursing assessment, incident report, notifying the physician and responsible party, and implementing treatment orders—was not followed in this case. The facility's abuse policy requires thorough investigation and documentation of all injuries of unknown source, but this was not completed for the resident's skin tear, resulting in a failure to respond appropriately to an alleged violation.
Failure to Consistently Complete Wound Treatments and Timely Identify Pressure Ulcers
Penalty
Summary
The facility failed to consistently complete wound treatments and timely identify and treat pressure ulcers for two residents reviewed for wounds. For one resident, the medical record showed that wound care orders for the sacrum, right buttock, and left heel were not followed as prescribed, with treatments omitted on specific dates. Additionally, staff applied a prescribed ointment more frequently than ordered. The resident required assistance with all activities of daily living and had multiple wounds documented upon admission. For another resident, there was a delay in the identification and treatment of a left heel wound. Although a clinician noted a possible pressure ulcer and recommended close monitoring and a wound care consult, nursing staff did not acknowledge the wound until two days later, and treatment orders were not implemented until six days after the initial identification. The resident also required staff assistance for most activities of daily living and had no pressure wounds documented at admission. The facility also failed to consistently complete and document weekly skin assessments as required by policy. In one instance, a weekly skin assessment was marked as completed in the medical record, but no supporting documentation was found. Interviews with facility staff confirmed that wound treatments were sometimes missed when the wound nurse was off duty and that communication lapses contributed to delays in wound identification and treatment.
Failure to Ensure Physician Completed Initial Comprehensive Visit
Penalty
Summary
A deficiency occurred when the facility failed to ensure that an initial comprehensive consultation was completed by a physician for one resident who was admitted with hypokalemia and required assistance with all activities of daily living. The resident was admitted and later transferred to the hospital, but the medical record review showed that the initial comprehensive visit was performed by a nurse practitioner, not the assigned physician, as required. There was no documentation of a written approval or recommendation by the physician for the resident's admission. Further review of the physician orders revealed that the physician signed an order agreeing with the care plans and diagnosis list only after the resident was no longer under the care of the facility. The facility's policy stated that a physician is responsible for the resident's first initial comprehensive visit. During interviews, facility leadership could not provide a timely or adequate explanation for the absence of the required physician documentation, and the only physician consult provided was completed after the nurse practitioner's initial visit.
Failure to Ensure Dignified Treatment During Room Transfer
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified manner when staff did not retrieve and deliver the resident's personal hygiene wipes after the resident was moved from one unit to another. Documentation in the resident's progress notes indicated that a nurse recorded the resident's need for wipes from their previous room and requested that the message be relayed to the day shift supervisor or maintenance. However, the Director of Nursing confirmed that the nurse should have personally retrieved and delivered the wipes to the resident's new room. The facility's policy on resident rights, which includes the right to a dignified existence and to be treated with respect, was not followed in this instance.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving one resident to the State Agency as required. On December 28, 2024, a resident reported feeling unsafe after a CNA made a verbal statement, "I could strangle somebody today," in response to the resident's request for assistance. The resident subsequently alleged that the CNA became aggressive and assaulted him, leading to the resident contacting a staff manager and the police. Documentation shows that the CNA was sent home and removed from the schedule pending investigation, and the police responded to the incident and took the resident's statement. Despite the resident's allegations and the involvement of law enforcement, there was no evidence that the facility reported the incident to the State Agency. The DON confirmed that the incident was not reported because the facility could not substantiate the allegation. Facility policy requires that all allegations of abuse be reported to the State Agency immediately, but this protocol was not followed in this case. The failure to report was identified through interviews, record reviews, and examination of facility documentation.
Failure to Follow Two-Person Assist for Bed Mobility Resulting in Resident Fall
Penalty
Summary
A resident with paraplegia, spinal cord injuries, bipolar disorder, pain, foot drop, and post-traumatic stress disorder was admitted to the facility and was assessed as non-ambulatory, with intact cognition, and dependent on staff for bed mobility. The resident's care plan specified a two-person assist for bed mobility. Despite this, a Certified Nurse Aide (CNA) provided incontinence care and attempted to turn the resident alone, during which the resident rolled out of bed and sustained a skin tear to the right knee. The CNA was not aware that two staff members were required for bed mobility and was not assisted by another staff member at the time of the incident. Facility documentation confirmed that the CNA was responsible for the resident's care at the time of the fall and that the care plan's requirement for a two-person assist was not followed. The facility's Fall Management Guidelines emphasized the need for individualized interventions to address fall risk factors, but these were not implemented as specified in the resident's care plan, resulting in an avoidable fall.
Failure to Provide Timely Pain Management Due to Medication Unavailability
Penalty
Summary
A resident with a history of paraplegia, spinal cord injury, wounds, bipolar disorder, adjustment disorder, and post-traumatic stress disorder was admitted to the facility and had a physician's order for oxycodone 20 mg every four hours as needed for pain. On one occasion, the resident requested pain medication but was informed by the nurse that the medication was completely out. The nurse attempted to contact the on-call physician without success and then reached out to the pharmacy, which indicated the medication would arrive later that evening. As a result, the resident experienced a delay of approximately 12 hours between doses, with a pain rating of 10 reported at the time the medication was finally administered. Review of the resident's Medication Administration Records for several months showed frequent requests and administration of pain medication every four hours as ordered. The Director of Nursing confirmed that the medication should have been reordered before running out and that alternative options, such as using the facility's back-up medication supply, were available. Documentation showed that oxycodone was stocked in the facility's emergency supply in various dosages, but these were not utilized during the incident. Facility policy also directed staff to refer to emergency pharmacy delivery and emergency supply kit procedures if a medication was not available.
Failure to Prevent Pressure Ulcer Due to Inadequate Intervention
Penalty
Summary
The facility failed to prevent a facility-acquired pressure ulcer for one resident, resulting in the development of an unstageable pressure ulcer on the left heel and a subsequent sepsis infection. The resident, who was admitted with diagnoses including dementia, type II diabetes, and atrial fibrillation, was observed with a severely impaired cognitive status. The care plan indicated a risk for pressure ulcer formation due to decreased mobility, and interventions included encouraging the resident to float heels and wear heel boots. However, documentation revealed that the resident developed an unstageable pressure ulcer on the left heel, attributed to wearing tight-fitting shoes while in bed. The facility's records showed that the resident had a history of refusing to remove shoes, which were identified as the cause of the wound. Despite this, there was no documentation of attempts to remove the shoes or any refusal by the resident prior to the discovery of the wound. The wound was first noted on 8/19/24, and the resident was subsequently seen by wound care services. The wound care team confirmed the presence of a swollen ankle and bleeding heel, and the resident was treated for cellulitis. The facility's documentation lacked evidence of interventions such as floating the resident's heels or providing heel boots, as outlined in the care plan. Interviews with facility staff, including the Wound Nurse Coordinator, Director of Nursing, and Medical Director, revealed that the wound was attributed to the resident's refusal to remove tight shoes. However, there was no prior documentation of such refusals or interventions to address the issue. The facility was unable to provide evidence of any attempts to remove the resident's shoes or documentation of the resident's refusal before the wound was discovered. This lack of documentation and intervention contributed to the development of the pressure ulcer and subsequent infection.
Inadequate Supervision and Transfer Assistance Leads to Resident Falls and Injuries
Penalty
Summary
The facility failed to ensure safe transfer and adequate supervision for a resident, resulting in multiple falls and injuries. One resident, who had a history of hemiplegia and osteoarthritis, reported falling multiple times due to inadequate assistance from staff. On one occasion, a CNA failed to assist the resident back into bed after using the bathroom, leading to a fall that resulted in a right oblique humerus fracture and a fracture of the right fifth digit. The resident's care plan required a two-person assist for transfers, but this was not followed, contributing to the fall and subsequent injuries. Another resident, with severe cognitive impairment and a history of repeated falls, was observed without the necessary Dycem on their wheelchair cushion, which was intended to prevent sliding. Despite a care plan intervention to apply Dycem after a previous fall, it was not consistently implemented, leading to another incident where the resident slid out of the wheelchair. The facility failed to investigate the root cause of the falls adequately and did not ensure that the care plan interventions were effectively implemented. A third resident, also with severe cognitive impairment, experienced multiple falls due to inadequate supervision and assistance. The resident was observed attempting to get out of bed without assistance, with their call light out of reach. Despite a history of falls and a care plan that included frequent rounding and assistance, the facility did not provide the necessary supervision to prevent further incidents. The lack of effective interventions and failure to adhere to care plans contributed to the resident's continued risk of falls.
Sanitation and Food Safety Deficiencies in Kitchen and Pantry Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and pantry areas, as well as during the transportation of food items. During an observation, a rolling cart in the kitchen was found with large portions of missing plastic edging, exposing porous particle board that was no longer smooth and easily cleanable. The Dietary Director confirmed the issue but did not provide an explanation for its continued use. Additionally, the Grind master coffee and hot water dispenser had a heavy buildup of coffee grounds and debris, and the dish machine room had missing grout between floor tiles with standing water and fruit flies present. The Maintenance Director was unaware of the missing grout issue. In the Cranbrook and [NAME] pantry, microwaves were observed with heavily rusted finishes on the inside top surface, which were confirmed by the Dietary Director as needing replacement. During the lunch trayline service, fruit cups were observed uncovered while being placed on trays and transported through hallways to resident rooms. The Dietary Director could not explain how the fruit cups would be protected from contamination during transport. These observations indicate a failure to adhere to the 2017 FDA Food Code standards for maintaining sanitary conditions and protecting food from contamination.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable ambient air temperatures in multiple resident rooms, as observed during a survey. On December 2, 2024, between 12:34 PM and 1:05 PM, the air temperatures in several resident rooms were measured and found to be below the required range of 71-81 degrees Fahrenheit. Specifically, temperatures ranged from 60 to 69 degrees Fahrenheit in rooms 100, 101, 103, 105, 107, 111, 201, 203, 205, and 207. In room 101, a resident was observed sitting in a wheelchair, wrapped in a blanket, wearing a winter hat, and stated she was cold. Additionally, a pillow was observed over the window in room 100 to block a draft. The Maintenance Director confirmed that room temperatures are monitored but not recorded, which is contrary to the facility's policy that requires maintaining comfortable and safe temperature levels as per Section 483.15 (4)(6) of the Quality of Life requirements.
Controlled Substance Documentation Deficiency
Penalty
Summary
The facility failed to ensure that all controlled substances were accounted for and accurately documented for a resident reviewed for pain management. The resident, who had a history of hemiplegia, hemiparesis, Charcot joint of the ankle, and Parkinson's Disease, reported frequent shortages of his pain medication, including oxycontin and oxycodone, leading to delays in receiving doses and experiencing pain. The resident's clinical records showed active orders for oxycodone and oxycontin, but discrepancies were found between the Medication Administration Record (MAR) and the Proof of Use forms, indicating issues with medication administration and documentation. The review of the resident's records revealed multiple instances where doses of oxycodone were documented as administered on the MAR without corresponding entries on the Proof of Use forms, and vice versa. There were also instances where tablets were pulled from the supply but not documented as administered or wasted, leading to inconsistencies in the medication count. Interviews with the resident's assigned nurse and the facility's Administrator in Training (AIT) confirmed the discrepancies and acknowledged the concerns regarding the facility's protocols for administering controlled substances. The facility's policy on controlled medications required licensed nurses to validate and document the receipt and administration of controlled substances accurately. However, the report highlighted several failures in adhering to these guidelines, resulting in unaccounted doses and discrepancies in medication records. The facility's Director of Nursing (DON) and AIT acknowledged the issues and confirmed that all medications pulled from the controlled substance supply needed to be accounted for on the MAR or through the process for wasting medications.
Duplicate Medication Error for a Resident
Penalty
Summary
The facility failed to prevent a significant medication error for one resident, resulting in the resident receiving duplicate doses of a diuretic medication, furosemide, on three separate days. The Consultant Pharmacist had identified duplicate orders for furosemide on the resident's eMAR and recommended that one of the orders be discontinued. Despite the nurse signing off on the pharmacist's recommendation, both orders remained active, and the resident received duplicate doses on three occasions. The error was not communicated to a physician, as there were no progress notes indicating that a physician was contacted when the error was identified. The Director of Nursing and the Administrator in Training acknowledged that the error occurred because some orders were not discontinued when the resident was readmitted from the hospital.
Failure to Implement Transmission-Based Precautions for Resident
Penalty
Summary
The facility failed to implement physician-ordered transmission-based precautions (TBP) for a resident identified as R20, who was placed on contact precautions for Vancomycin-resistant Enterococci (VRE). On the morning of December 2, a Certified Nursing Assistant (CNA) was observed entering R20's room to provide incontinence care without any signage indicating contact precautions or personal protective equipment (PPE) available outside the room. Later, R20 was seen interacting with another resident near the nurse's station and was taken to the dining room, despite the physician's orders for contact precautions starting on November 29. The Infection Control Preventionist, RN 'BB', later placed the necessary signage and PPE outside R20's room. Interviews with the Director of Nursing (DON) and the Administrator in Training (AIT) revealed that R20 was supposed to be on contact precautions as per the physician's order. However, R20 was kept in the room due to incontinence issues and refusal to wear a brief, with the condition that if the family and resident agreed to wear a brief, R20 could leave the room during the isolation period. The facility's policy on infection control and transmission-based precautions was not followed, as it required hand hygiene, PPE use, and limiting resident movement outside the room to medically necessary purposes.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of several residents, as evidenced by multiple incidents involving inappropriate staff behavior and inadequate care. One resident reported that a CNA rudely instructed them to shampoo their own hair during a shower. Another resident was left exposed on a bedpan with the door open, compromising their privacy, and the CNA responsible admitted to not ensuring the door was closed. A third resident experienced a lack of preparedness during a shower, with the CNA leaving multiple times to retrieve supplies and engaging with their cell phone instead of assisting the resident. Additionally, a family member was inappropriately asked to clean a resident, which they found to be the CNA's responsibility. Further incidents included a resident who was not offered assistance when they requested it, and another instance where a CNA caused pain by improperly handling a resident's bandaged foot. A resident also reported being discouraged from using their call light during meal times. These incidents were reported to the facility's administration, who acknowledged the complaints and expressed an expectation for residents to be treated with respect and dignity. The facility's policy on dignity emphasizes the importance of treating residents with respect and maintaining their privacy, which was not adhered to in these cases.
Failure to Ensure Timely PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure a timely referral for a Level II evaluation for a resident with mental disorders and intellectual disabilities. The resident, who was admitted and readmitted with diagnoses including paranoid schizophrenia, vascular dementia, schizoaffective disorder bipolar type, and major depressive disorder, had severely impaired cognition. A review of the resident's PASARR Level I Screening form indicated the presence of mental illness and dementia, necessitating a referral to the local Community Mental Health Services Program for a Level II evaluation. However, there was no evidence of a Level II evaluation or an exemption request form in the resident's clinical record. The Director of Social Work was unable to locate the Level II evaluation initially and later reported that the exemption form was not completed until a day after the inquiry. The facility's policy on PASARR, revised in 2020, outlines the requirement for a two-level screening process to ensure appropriate placement and service determination for individuals with mental illness or intellectual disabilities. The policy mandates that the PASARR process be completed prior to admission, after significant changes in the resident's condition, and at least annually. The deficiency arose from the failure to adhere to these requirements, as evidenced by the lack of timely documentation and referral for the resident in question.
Deficiencies in Resident Care and Medication Administration
Penalty
Summary
The facility failed to timely identify and assess a facial bruise for a resident with severely impaired cognition. The resident was observed with a brownish bruise below their left eye, and there was no documentation of the bruise in the resident's clinical record until eight days after an unwitnessed fall. The facility did not provide additional investigation reports, and a skin assessment conducted two days after the fall did not note any bruising. The nurse who documented the bruise reported notifying the supervisor, but no further investigation was conducted as it was assumed the bruise was from the fall. The facility also failed to ensure medications were administered on time and according to physician's orders for two residents. One resident was heard yelling in pain and had not received their morning medications, which were scheduled for 9:00 AM but were administered two and a half hours late. The assigned nurse confirmed the delay and cited reasons such as looking for supplies and talking to family. Another resident reported chest pain and requested pain medication, which was administered an hour and a half after the request. The facility policy required medications to be administered within a one-hour window of the scheduled time, and any delays should have been communicated to a physician. Additionally, the facility failed to ensure a physician's order for wound care for a resident. The resident was observed with an undated bulky dressing on their right elbow and forearm, but there was no order for the dressing in the resident's records. The assigned nurse was unaware of the order and did not apply the dressing, indicating it was done on a previous shift. The facility policy required treatments to be ordered by a medical practitioner and dressings to be dated and initialed by the licensed nurse when applied.
Failure to Ensure Proper PICC Line Dressing Orders and Monitoring
Penalty
Summary
The facility failed to ensure appropriate orders for PICC line dressing changes and monitoring for two residents. One resident, who was receiving antibiotics through a PICC line in their right arm, was observed with a dressing that was mostly hanging loose and not properly adhered. This resident had been admitted with diagnoses including a cutaneous abscess and cellulitis, and had moderately impaired cognition. Despite the need for regular dressing changes, there was a gap in the orders for the PICC line dressing change from 11/26/24 to 12/2/24, and the existing order lacked specific details about the dressing. The Administrator in Training (AIT) and the current Director of Nursing (DON) were interviewed and acknowledged that an order should have been in place upon the resident's admission with a PICC line. The AIT explained that a template was used for entering orders, but it was not properly utilized in this case, leading to the absence of a specific order for the PICC line dressing change. The observation of the dressing being barely attached and hanging loosely indicated a failure to adhere to the facility's policy for PICC line care.
Failure to Follow Up on Guardianship Process
Penalty
Summary
The facility failed to follow up on the guardianship process for a resident who was deemed incompetent to make complex medical and financial decisions. A competency evaluation dated 10/18/24, signed by two physicians, indicated that the resident was not competent to make such decisions. A progress note from 10/17/24 by the Social Work Director documented that the resident's son was informed of the need for a guardian and that he planned to file for emergency guardianship. However, there was no evidence of any follow-up by the Social Work Department after this date, as confirmed during an interview with the Social Work Director on 12/4/24. The former Director of Nursing, now an Administrator in Training, confirmed that the Social Work Department was responsible for this follow-up.
Failure to Document Pharmacist's Recommendations in Resident's Record
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews conducted by the consultant pharmacist were reviewed by the medication provider for recommendations to act on. This deficiency was identified for one resident out of five reviewed for unnecessary medications. The resident in question was admitted with diagnoses including chronic respiratory failure, chronic kidney disease, and type II diabetes. The consultant pharmacist reviewed the resident's medication and noted irregularities and/or recommendations on a specific date. However, there was no documentation in the resident's clinical record indicating what these irregularities or recommendations were. During an interview and record review, the Director of Nursing/Administrator in Training acknowledged that all responses to the consulting pharmacist should be documented in the resident's clinical record but was unable to locate the necessary documentation in the electronic record before the end of the survey.
Failure to Offer Seasonal Influenza Vaccine
Penalty
Summary
The facility failed to offer the 2024-2025 seasonal influenza vaccine to a resident, identified as R49, who was reviewed for influenza vaccines. During a review of R49's immunization records, it was found that the last documented entry for the influenza vaccine was on September 10, 2024, indicating that the 2023-2024 seasonal vaccine was not offered because the resident was admitted after the influenza season. There was no evidence that the 2024-2025 vaccine had been offered at the beginning of the new flu season. An interview with the Infection Control Preventionist confirmed that the vaccine had not been offered or administered to the resident. Additionally, the facility's policy on vaccination, dated October 2023, did not address the offering of the influenza vaccine at the start of the new flu season, which is between October 1st and March 31st each year.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely follow-up dental services to a resident, identified as R25, who was observed to be missing teeth on the lower jaw and wearing dentures on the upper jaw. The resident expressed a desire to see a dentist and obtain bottom dentures. Despite being alert and having intact cognition, as indicated by a BIMS score of 15/15, there was no documentation in the resident's clinical record of having received dental services since a comprehensive oral evaluation on 8/21/23. During this evaluation, it was noted that two lower teeth were to be extracted as needed in preparation for a lower denture, but no follow-up services were documented. Interviews with facility staff, including the Social Worker Director and the Director of Nursing/Administrator in Training, revealed a lack of clarity and documentation regarding the resident's dental care. The Social Worker Director mentioned that residents were seen annually or as needed, but could not provide documentation of R25 refusing follow-up dental services. The Director of Nursing/Administrator in Training was unable to explain why there had been no follow-up within the year following the last dental appointment. The facility's policy on dental services requires documentation of oral/dental status according to assessment findings, which was not adhered to in this case.
Failure to Document and Complete Accurate Skin Assessments
Penalty
Summary
The facility failed to ensure skin assessments were documented, completed accurately, and timely for a resident with a history of Metabolic Encephalopathy, Cellulitis of the right lower limb, and Sepsis. The resident was readmitted from the hospital and had a physician's order for weekly skin evaluations. However, a review of the medical records revealed that no accurate documentation of the resident's skin presentation was completed from mid-March to mid-April, despite the Treatment Administration Record indicating that weekly skin evaluations were performed during this period. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the assessments were documented as completed in the Treatment Administration Record but were not properly recorded in the Total Body Skin Evaluation under the medical records assessment tab. The DON acknowledged the issue and indicated that a past non-compliance action plan had been initiated to address the lack of proper documentation, but the problem persisted for the resident in question. The facility's Skin and Wound Guidelines also emphasized the importance of documenting body audits in the residents' electronic medical records, which was not adhered to in this case.
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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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