Aria Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lansing, Michigan.
- Location
- 707 Armstrong, Lansing, Michigan 48911
- CMS Provider Number
- 235561
- Inspections on file
- 29
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Aria Nursing And Rehabilitation during CMS and state inspections, most recent first.
A cognitively intact resident with multiple sclerosis and epilepsy reported that another resident, who appeared intoxicated and had an open can of beer, struck her left arm in a day room, with a RN and CNA hearing a slap-like sound and the resident cry out, and the aggressor later admitting he had "smacked" her arm after drinking. In a separate incident, a resident with dementia and cardiac and diabetic conditions became upset over a wallet he insisted was his, and multiple staff witnesses reported that the former NHA raised his voice, got close to the resident, pointed at him, and called him a profane name while the resident was hollering and swearing, with the resident later recalling that cussing words were used toward him.
A resident with morbid obesity, multiple comorbidities, moderately impaired decision-making, and documented dependence for bed mobility had a care plan requiring a two-person assist for rolling in bed. During early-morning incontinence care, a CNA, believing the resident was an assist of one based on the Kardex, rolled the resident away from herself while the bed was elevated, causing the resident to fall to the floor. Staff found the resident face down next to the elevated bed with a large right lower-leg laceration and pain, and EMS transported the resident to the hospital, where the wound required 24 sutures and internal drains. The facility’s investigation materials lacked the CNA’s reported written witness statement, and the DON acknowledged that staff failed to follow the care-planned two-person assist for bed mobility, resulting in the fall with injury.
A cognitively intact resident with insulin‑dependent DM and other chronic conditions experienced a significant medication error when an RN administered 52 units of short‑acting Novolog instead of the ordered long‑acting insulin, resulting in wrong medication and wrong strength/quantity. Family members reported that the resident was transferred to the hospital after this large dose of fast‑acting insulin, and facility documentation, including a medication error form, nurse progress note, and physician note, confirmed the mis‑administration. The DON acknowledged that a medication error had occurred, and later observation found the resident non‑verbal and non‑responsive with hospice services in place.
A resident with multiple diagnoses and a care plan requiring calm communication was subjected to profane and inappropriate language by a CNA, as confirmed by both the resident and a housekeeper. The CNA admitted to using inappropriate language in response to the resident, and the facility's investigation substantiated the verbal misconduct, resulting in a failure to honor the resident's right to dignity and respectful treatment.
A resident with multiple diagnoses, including Parkinson's Disease and mental health conditions, was present when a CNA was overheard using profane language in their room. The incident was reported internally but not reported to the State Agency within the required two-hour timeframe, with the delay confirmed by the NHA, who could not explain the late reporting.
Surveyors identified widespread failures in cleaning and maintenance throughout the facility, including soiled ventilation grills, damaged flooring, stained ceiling tiles, loose plumbing fixtures, and unaddressed work orders. These deficiencies affected 83 residents and were not documented in the facility's maintenance system, despite policies requiring daily cleaning and prompt repairs.
Surveyors found that medications were not consistently labeled or stored according to professional standards. A resident was found with a cup of pills left on the bedside table without assessment for self-administration, and a multi-dose inhaler was discovered on a medication cart without the required date of opening. Both the RN and DON confirmed these actions were not in line with facility policy.
Surveyors identified deficiencies in the cleaning and maintenance of food service equipment, as well as failures to properly date mark ready-to-eat food items. Multiple kitchen appliances and surfaces were found soiled with dust, dirt, and food residue, and some food products lacked required open or discard dates. These issues were observed during a kitchen tour and confirmed through interviews and policy reviews.
Surveyors found that two outdoor waste receptacles were not properly maintained and the surrounding concrete pad was not cleaned, with accumulated debris and damaged receptacle components observed. Facility policy required regular trash removal and cleanliness, but no related work orders were found. These deficiencies affected 83 residents.
A resident with multiple medical conditions and moderate cognitive impairment was prescribed Olanzapine, an antipsychotic, without being informed of the medication's benefits, risks, or alternatives. The social worker and DON confirmed that no consent documentation was present, and the resident was unable to state the reason for receiving the medication, despite facility policy requiring such information be provided before starting psychotropic drugs.
The facility did not promptly address or resolve multiple resident grievances, including missing clothing, inappropriate food options, and removal of privacy amenities. Grievance forms were incomplete and lacked resident signatures, and staff interviews confirmed ongoing issues with the grievance process and laundry procedures, resulting in unresolved concerns and resident frustration.
The facility failed to properly document and monitor the use of psychotropic medications for three residents, including missing or inconsistent diagnoses to support antipsychotic use, incomplete behavioral and side effect monitoring, unacknowledged pharmacy recommendations for dose reduction, and PRN antianxiety medication orders that exceeded regulatory time limits.
A resident with a history of repeated falls and multiple diagnoses experienced several falls over six months, some resulting in injury. Despite these incidents, the care plan was not consistently updated with new interventions, and staff discussions about the resident's needs were not reflected in the care plan documentation. This failure to revise the care plan led to the potential for further falls and unmet care needs.
The facility failed to provide adequate care for pressure ulcers, leading to the deterioration of wounds in two residents. One resident developed a Stage 2 pressure ulcer that worsened to an unstageable ulcer, resulting in hospitalization and surgery for osteomyelitis. The facility did not consistently follow the wound care plan, and incorrect treatments were administered. Another resident developed pressure sores, but the facility failed to document a wound assessment, notify the guardian, or order appropriate treatment. The care plans were not updated, and staff were unaware of the pressure injuries, leading to a lack of treatment.
The facility failed to administer medications according to physician-ordered parameters for three residents, leading to medication errors. A resident with heart disease received Metoprolol despite low blood pressure readings, another with atrial fibrillation was given Entresto without proper blood pressure checks, and a third with hypertension received Lisinopril without any blood pressure assessments. The DON confirmed these errors, which violated the facility's medication administration policy.
A resident reported being hit by a mechanical lift sling, resulting in welts, but the incident was not documented or investigated by the facility. The NHA considered it an accident and took no action against the CNA involved, despite the resident's report and photographic evidence of the injury.
A resident reported being hit by a mechanical lift sling, resulting in welts. The incident was not documented or reported by the NHA, who deemed it accidental. The CNA admitted to "goofing off" with the sling. The facility failed to prevent abuse and did not investigate or report the incident, leading to a deficiency citation.
Failure to Prevent Resident-to-Resident Physical Abuse and Administrator Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect one resident from physical abuse by another resident and another resident from verbal abuse by a staff member. One resident with multiple sclerosis and epilepsy, cognitively intact per a recent MDS, reported that approximately three weeks prior she was in the day room when another resident, who appeared intoxicated and had an open can of beer, choked her and then slapped her left arm hard enough to leave red marks. On the date of the incident, a RN passing medications just outside the day room heard a slap-like sound and the resident say “ouch,” then found the alleged aggressor in a wheelchair next to the resident and observed mild redness on the resident’s left upper arm. A CNA in the day room also heard a slapping noise and the resident call out, then turned and saw the alleged aggressor sitting next to her. The facility’s investigation substantiated resident-to-resident physical abuse based on the aggressor striking the resident’s left upper arm, though the choking allegation could not be substantiated. The resident alleged that the aggressor had been intoxicated and that he grabbed the front of her neck with one hand, making her unable to breathe, and then slapped her arm. The aggressor’s medical record showed moderate cognitive impairment on the BIMS, and he later acknowledged that he “smacked” the resident’s arm, stating he had been drinking beer at a family member’s house before being dropped off at the facility and did not remember the incident, but understood from others that it was an open-hand smack. The facility’s investigation documented that he appeared intoxicated at the time, had an open can of beer in his wheelchair, and had been watching the resident talk to another male resident, which he reportedly did not like, before approaching her. Staff present in or near the day room did not prevent the physical contact, and the abuse occurred in a common area while the aggressor was in possession of alcohol and visibly intoxicated. The deficiency also includes an incident of verbal abuse toward another resident by the former Nursing Home Administrator (NHA). This resident, with chronic diastolic heart failure, diabetes, and unspecified dementia and severe cognitive impairment per a recent MDS, was in his room with a wallet that staff believed belonged to another resident. During an attempt by staff, including the former NHA, Social Services Assistant, and Scheduler, to address the wallet issue, the resident became upset, hollering, swearing, and insisting the wallet and money were his. Multiple staff witnesses reported that the former NHA raised his voice, got in the resident’s face, pointed at him, and called him a “mother f**ker” after the resident swore at him, while the resident later recalled that the man involved swore and used “cussing words” toward him. The facility’s investigation determined that the wallet was in fact the resident’s, and staff accounts consistently described the former NHA’s use of profanity and raised voice toward the resident during the interaction.
Failure to Follow Bed-Mobility Care Plan Leads to Fall and Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident safety and to implement care-planned interventions during staff-assisted care, resulting in a resident falling from an elevated bed and sustaining a serious leg laceration. The resident was an older female with chronic heart failure, diabetes, morbid obesity, major depression, and anxiety disorder. Her MDS showed a BIM score of 11, indicating moderately impaired decision-making, and documented that she was dependent on staff for toileting, dressing, bathing, and rolling in bed. Her care plan, dated 1/2/26, specified that she had a functional ability deficit related to morbid obesity and weakness, and required a two-person assist for all aspects of bed mobility, including rolling side to side. On the morning of the fall, a CNA was providing incontinence care to the resident and rolled her away from herself while the bed was elevated to between knee and hip height. During this maneuver, the resident fell out of the bed to the floor and began screaming in pain. Another CNA and a nurse responded and observed the resident lying face down on the floor next to the elevated bed, with blood pooling under her right knee and a large open wound on her right lower leg. The resident complained of back and leg pain. Emergency services were called, and the resident was transported to the hospital, where she was treated for a significant laceration of the right lower leg requiring 24 sutures and placement of internal drains. Record review showed that the resident’s care plan required a two-person assist for bed mobility, but the CNA who provided care at the time of the fall believed the resident was an assist of one based on the Kardex and did not verify this information. The CNA reported that she had completed a written witness statement and was later educated to follow the Kardex and to roll residents toward, not away from, herself during care. However, the administrator and DON were unable to produce any written witness statements as part of the facility’s investigation, and the investigation materials provided did not include such documentation. The DON acknowledged that the facility failed to follow the care-planned interventions for two-person assist with bed mobility, which led to the resident’s fall with injury, and stated that staff were expected to follow care plans and Kardex and to roll residents toward themselves during in-bed care.
Significant Insulin Administration Error Involving Wrong Insulin Type and Dose
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for one cognitively intact resident with insulin‑dependent diabetes, anxiety, and depression. The resident’s daughter had submitted a complaint to the state alleging that insulin was not administered according to physician orders. Review of the resident’s records showed that the resident was hospitalized and not present in the facility at the time of survey. During interviews, the resident’s daughter and son both reported that the resident had been transferred to the hospital after receiving a large dose of fast‑acting insulin instead of the prescribed long‑acting insulin. The DON acknowledged that the resident had a medication error. Further review of the medical record and facility documentation confirmed that the resident was administered 52 units of Novolog (short‑acting insulin) instead of the ordered long‑acting insulin, constituting wrong medication and wrong strength/quantity. A nurse involved in the incident reported that the fast‑acting insulin was given in error in place of the long‑acting insulin and that this was reported to the DON. A nurse progress note documented that the resident returned from the emergency department with EMS, with EMS reporting that the resident’s blood glucose never dropped below 100 and the event was uneventful. A physician note documented that staff reported the resident had been transferred to the emergency department after mis‑administration of 52 units of short‑acting insulin. During a later observation, the resident was seen in bed, non‑verbal and non‑responsive to questions, with her son at the bedside and hospice services in place.
Failure to Treat Resident with Dignity and Respect Due to Staff Use of Inappropriate Language
Penalty
Summary
A resident with diagnoses including Parkinson's Disease, anxiety disorder, major depressive disorder, and post-traumatic stress disorder, who was cognitively intact and required two-person assistance with activities of daily living, was not treated with dignity and respect. The resident's care plan and Kardex specified that staff should approach and speak to the resident in a calm, quiet manner. However, the resident reported that a Certified Nursing Assistant (CNA) used obscene and inappropriate language during an interaction, including profanities and derogatory remarks. This incident was corroborated by a housekeeper who overheard the CNA loudly using profane language inside the resident's room. Further interviews confirmed that the CNA admitted to responding to the resident with inappropriate language after being called names by the resident. The facility's investigation substantiated that the staff member was verbally inappropriate in the presence of the resident. The incident demonstrated a failure to honor the resident's right to a dignified existence and respectful communication, as required by the resident's care plan and facility policy.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation to the State Agency for one resident. The resident, who was cognitively intact and had diagnoses including Parkinson's Disease, anxiety disorder, major depressive disorder, and post-traumatic stress disorder, was present in their room when a CNA was overheard by a housekeeper repeatedly using profane language directed at the resident. The housekeeper reported the incident to the housekeeping supervisor and the administrator. Although the incident occurred and was discovered in the early afternoon, it was not reported to the State Agency until over seven hours later, exceeding the required two-hour reporting timeframe. The Nursing Home Administrator confirmed the delay and was unable to provide an explanation for the late reporting.
Failure to Maintain Clean and Safe Physical Environment
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 83 residents. During environmental tours of various facility areas, surveyors observed multiple instances of unaddressed soiling, damage, and maintenance issues. These included missing or damaged cabinet components, soiled ventilation grills, stained and warped ceiling tiles, loose or damaged commode seats and supports, leaking plumbing, and soiled or damaged flooring. Additionally, equipment such as microwaves and box fans were found to be corroded or heavily soiled, and air filters in PTAC units were observed with accumulated dust and dirt. In several resident rooms, commode base caulking was found to be etched, scored, stained, or particulate, and some hand sinks were draining slowly or not at all. Interviews with the Director of Maintenance and Housekeeping Director revealed that while a work order system (TELS) was in place, many of the observed deficiencies had not been entered into the system or addressed. For example, missing flooring tiles in a janitor closet had been unaddressed since June 2022, and no work orders were found in the TELS system for the specific maintenance concerns identified during the survey. Staff acknowledged the issues when pointed out and indicated intentions to submit work orders, but these actions had not occurred prior to the survey. A review of the facility's housekeeping policy indicated that cleaning of non-carpeted floors and other horizontal surfaces should occur daily and more frequently if visibly soiled. However, the observations made during the survey demonstrated that these procedures were not consistently followed, as evidenced by the widespread presence of dust, dirt, stains, and damaged surfaces throughout both common and resident areas. The lack of effective cleaning and maintenance increased the likelihood of cross-contamination, bacterial harborage, and decreased air quality for residents, staff, and the public.
Failure to Properly Label and Store Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not consistently labeled and stored according to accepted professional standards. In one instance, a resident was found with a medication cup containing four to five pills left unattended on the bedside table for approximately 30 minutes while the resident was sleeping. The resident had not been assessed for self-administration of medications, and the Director of Nursing confirmed that residents were not permitted to self-administer medications. This indicates that staff failed to ensure medications were administered directly to the resident and not left at the bedside. Additionally, during a review of a medication cart, a multi-dose inhaler (Fluticasone Propionate Inhalation Aerosol 220 MCG) was found open and not dated as required by facility policy and professional standards. The Registered Nurse acknowledged that all medications should be dated when opened and could not explain why this was not done. The Director of Nursing also confirmed that it was expected practice to date all multi-dose medications upon opening, but could not account for the lapse in this instance.
Deficiencies in Food Service Equipment Sanitation and Date Marking
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations, specifically related to the cleaning and maintenance of food service equipment and the date marking of potentially hazardous ready-to-eat food products. During an initial tour of the kitchen, several pieces of equipment, including the Avantco 2-Door Reach-In Cooler and Vulcan convection ovens, were found with non-functional interior light bulbs. Additionally, the interior and exterior surfaces of refrigerators and ovens, as well as the can opener assembly, were noted to be soiled with accumulated and encrusted dust, dirt, and food residue. Overhead light lens covers, ceiling-mounted return-air-exhaust ventilation grills, and the mechanical dish machine ventilation hood were also observed to be heavily soiled with dust and debris. Further inspection revealed that food items such as a gallon of milk and a container of cottage cheese stored in the reach-in cooler were not properly date marked to indicate when they should be consumed or discarded, despite being open and held for more than 24 hours. The manufacturer's use-by dates were visible, but there was no effective open or discard date as required by the FDA Model Food Code. These findings were confirmed through interviews with the Dietary Director, who acknowledged the issues and indicated intentions to address them. Record reviews of the facility's policies and procedures for dietary cleaning, sanitation, and food handling confirmed that the facility is required to maintain kitchen sanitation and comply with time and temperature requirements to prevent foodborne illness. However, the observed conditions did not align with these policies, as equipment and non-food contact surfaces were not kept clean, and proper food handling techniques, such as date marking, were not consistently followed.
Improper Maintenance and Cleaning of Outdoor Waste Receptacles
Penalty
Summary
Surveyors observed that the facility failed to properly maintain two out of three outdoor waste receptacles and did not clean the concrete pad surface where the receptacles were located. Specifically, accumulated dirt and debris, including paper products, plastic bottles, a plastic milk crate, and a wooden pallet, were present on the concrete pad. Additionally, one of four receptacle plastic lids was missing, and one of four receptacle slider panels was broken, with a hole measuring approximately 6 inches by 6 inches. Review of facility policy indicated that trash should be removed on a specific schedule and the area surrounding the dumpster kept free of debris. However, a review of work orders for the past 180 days showed no entries related to maintenance or cleaning of the outdoor waste receptacles or the concrete pad surface. These deficiencies affected 83 residents.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including chronic kidney disease, bipolar disorder, and depression, was prescribed Olanzapine, an antipsychotic medication, without being informed of the associated benefits, risks, or alternatives. The resident had a moderate cognitive impairment, as indicated by a BIMS score of 12 out of 15. Review of the medical record showed no documentation of consent or evidence that the resident or their responsible party had been provided with information regarding the use of Olanzapine. Interviews with facility staff revealed that the social worker was responsible for ensuring that residents or their representatives received and signed consent forms for psychotropic medications. However, the social worker was unable to provide any documentation of consent for this resident, and the DON confirmed that no such consent was present in the medical record. The resident was also unable to explain why they were receiving the antipsychotic medication. Facility policy required that residents and/or their representatives be informed of the benefits, risks, and alternatives before initiating or increasing psychotropic medications, but this procedure was not followed in this case.
Failure to Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to act promptly on grievances reported during resident council meetings and did not provide adequate responses to grievances for six of nine residents, as evidenced by a review of resident council meeting minutes and grievance forms. Concerns and complaints, such as missing clothing, inappropriate food options, and removal of a phone that provided privacy, were repeatedly documented over several months without resolution or proper documentation indicating that the issues had been addressed. Grievance forms were found to be incomplete, lacking documentation of resolution and resident signatures to confirm satisfaction with outcomes. Residents expressed ongoing frustration during council meetings, reporting that missing clothing issues persisted for weeks or months, with some residents observing others wearing their clothes and staff failing to act when notified. Additional concerns included being served food that did not meet dietary needs or preferences, repeated offering of undesirable alternatives, and the removal of a phone that previously allowed for private conversations. Multiple residents reported receiving cold food, sour milk, and food they were allergic to, with all nine residents at the meeting sharing that their grievances remained unresolved. Interviews with facility staff revealed a lack of consistent follow-through in the grievance process. The Activity Director and other staff described the process for handling grievances but acknowledged that forms were not always completed fully or signed by residents to indicate satisfaction. The Housekeeping Director detailed ongoing issues with the laundry process, including improper labeling of clothing and incomplete personal item lists, which contributed to the unresolved complaints about missing clothing. Despite these issues being discussed in daily meetings, no changes had been made to address the underlying problems.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper documentation and monitoring for the use of psychotropic medications for three out of five residents reviewed. For one resident with dementia and depression, Risperidone was prescribed without a documented allowable diagnosis to support its use, and the diagnosis of 'depression with psychotic features' was not consistently reflected in the medical record or on the active diagnoses list. The resident's care plan and behavioral documentation were incomplete, and not all possible side effects listed in the informed consent were included on the treatment administration record for staff monitoring. Additionally, a pharmacy recommendation for a gradual dose reduction (GDR) of Risperidone was not acknowledged or acted upon by the physician, and there was a lack of clear process ownership for monitoring psychotropic medications among staff. Another resident received multiple PRN (as needed) orders for Ativan, an antianxiety medication, with durations exceeding the regulatory 14-day limit for PRN antianxiety medications. These orders were not appropriately limited or reviewed within the required timeframe, indicating a failure to comply with federal regulations regarding the use of PRN psychotropic medications. A third resident was prescribed both an antipsychotic (Olanzapine) and an antidepressant (Trazodone) without corresponding physician orders for monitoring side effects. The Director of Nursing confirmed that monitoring for side effects should have been ordered and documented, but could not provide evidence that this was done. The facility's policy required monitoring for efficacy, side effects, and adverse consequences of psychoactive medications, but this was not followed for the resident in question.
Failure to Revise Care Plan After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was revised to address the ongoing care needs of a resident with a history of repeated falls. The resident, who had diagnoses including repeated falls, diabetes, left hip pain, bipolar disorder, and dementia, experienced eight falls over a six-month period. Despite multiple incidents, including falls in the bathroom and bedroom, care plan interventions were either not updated or only minimally addressed, such as ensuring toileting after meals or applying anti-rollback bars to the wheelchair. Several falls resulted in injuries, including a 3 cm abrasion above the left eyebrow and a laceration with a knot, yet no new care plan interventions were implemented following these events. Interviews with staff revealed that the resident often attempted to self-transfer, leading to falls, and that while incidents were discussed in daily meetings, these discussions did not result in updates to the care plan. The care plan was not consistently revised to reflect the resident's changing needs or to implement new interventions after each fall. Documentation showed that recommendations, such as transferring the resident to the unit dayroom with nursing staff, were discussed but not added to the care plan or put into practice. This lack of timely and comprehensive care plan revision resulted in the potential for additional falls and unmet care needs.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure injuries, leading to the deterioration of wounds and subsequent hospitalization. Resident #1, a cognitively intact male with Type II Diabetes and other health issues, developed a Stage 2 pressure ulcer on his left heel during his stay. Despite initial improvement, the wound care plan was not consistently followed, and incorrect treatments were administered. The wound deteriorated to an unstageable pressure ulcer, and the resident was hospitalized with osteomyelitis, requiring surgical intervention. Resident #6, a cognitively intact female with muscle weakness and morbid obesity, was found to have a pressure sore on her left thigh and a new red spot on her right buttock. The facility failed to document a wound assessment, notify the guardian, or order appropriate treatment upon identification of the pressure injury. The resident's care plan was not updated with necessary interventions, and the staff was unaware of the pressure injuries, leading to a lack of treatment. The facility's failure to adhere to professional standards of practice for pressure ulcer care resulted in the worsening of residents' conditions. The care plans were not revised to reflect changes in the residents' skin conditions, and the necessary notifications and treatments were not completed. This lack of appropriate care and communication contributed to the deterioration of the residents' pressure injuries.
Medication Administration Errors Due to Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered according to physician-ordered parameters for three residents, resulting in medication errors. Resident #7, a male with heart disease and hypertension, received Metoprolol despite blood pressure readings that were below the prescribed parameters on multiple occasions. Additionally, there were instances where his blood pressure was not assessed prior to medication administration, relying instead on outdated readings. Resident #8, a male with atrial fibrillation, was administered Entresto even when his blood pressure readings were below the ordered parameters, and on some occasions, his blood pressure was not assessed before medication administration. Resident #10, a female with hypertension, received Lisinopril throughout June without any blood pressure assessments to ensure compliance with the ordered parameters. The Director of Nursing confirmed that medications for these residents were administered outside of parameters or without necessary vital sign assessments. The facility's policy on medication administration, last revised in April 2019, requires that medications be administered in accordance with prescriber orders, including any necessary vital sign checks. The failure to adhere to these protocols led to the administration of medications without verifying that the residents' vital signs were within the prescribed limits, contributing to the cited deficiencies.
Failure to Prevent and Investigate Staff-to-Resident Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident abuse and did not adequately protect residents or investigate allegations, leading to the potential for continued abuse. A resident, who was cognitively intact, reported being hit on the back by a mechanical lift sling, resulting in welts. The incident was witnessed by others, and the resident had photographic evidence of the injuries. Despite the resident reporting the incident to the Nursing Home Administrator (NHA), it was not documented or addressed in the medical record. The NHA did not report the incident, considering it an accident rather than abuse, and took no disciplinary action against the involved CNA. The CNA admitted to goofing off with the mechanical lift sling, which led to the resident being hit. The NHA acknowledged discussing the incident with the resident, who expressed that the hit was painful but did not want to get anyone in trouble. The lack of documentation and failure to report or investigate the incident contributed to the deficiency.
Failure to Report and Investigate Staff-to-Resident Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident abuse and did not properly investigate or report the incident to the state agency. A resident, who was cognitively intact, reported being hit on the back by a mechanical lift sling, which left welts. The incident occurred when a CNA was "goofing off" with the sling, and the resident reported it to the Nursing Home Administrator (NHA) two weeks later. Despite the resident showing photographic evidence of the injury, the incident was not documented in the medical record. The NHA did not report the incident, believing it was an accident and not intentional abuse. The NHA also did not take any disciplinary action against the CNA involved, nor did he educate staff on the incident. The CNA admitted to "goofing off" with the sling, which led to the resident being hit. The NHA acknowledged discussing the incident with the resident, who expressed that the hit was painful but did not want to get anyone in trouble. The lack of documentation and failure to report the incident resulted in a deficiency citation for the facility.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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