Autumnwood Of Mcbain
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcbain, Michigan.
- Location
- 220 South Hughston Street, Mcbain, Michigan 49657
- CMS Provider Number
- 235438
- Inspections on file
- 20
- Latest survey
- May 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Autumnwood Of Mcbain during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was admitted for respite care and experienced a significant medication error when their Carbidopa/Levodopa and Levothyroxine orders were transposed, leading to multiple overdoses of Levothyroxine. The error was not identified or corrected by nursing or medical staff, resulting in the resident's rapid decline, severe adverse effects, and eventual death.
A resident with multiple chronic conditions was admitted for respite care and experienced a significant medication error when Carbidopa/Levodopa and Levothyroxine orders were transposed during admission. The resident received excessive Levothyroxine doses and insufficient Carbidopa/Levodopa due to improper transcription and lack of a documented double-check by nursing staff. The error persisted for several days, leading to severe adverse effects and a marked decline in the resident's condition, ultimately resulting in death after discharge.
A resident with multiple chronic conditions was admitted and received an incorrect, excessive dose of Levothyroxine due to a transcription error and lack of verification by nursing staff. Despite abnormal symptoms and vital signs, staff did not question the unusual dosing frequency or check the original orders, resulting in the resident receiving five times the intended dose for several days and a significant decline in their condition.
Inadequate staffing at the facility resulted in residents being left in soiled conditions and experiencing long wait times for assistance. One resident with a leaking colostomy bag was not attended to promptly, while another waited 30 minutes for repositioning. Staff shortages, particularly during weekends and evening shifts, contributed to these deficiencies, as confirmed by staff and resident interviews.
The facility failed to store food according to professional standards, with expired and undated items found during a kitchen tour. Issues included wilted cabbage, rotten potatoes, a broken egg, moldy tomatoes, and exposed vegetarian patties. Additionally, hot dogs had an unclear use-by date. Damaged cabinetry near an ice machine was also noted, with past leakage issues confirmed. These deficiencies risked foodborne illness among 89 residents.
The facility failed to maintain functioning exhaust ventilation in resident bathrooms on the 300 Hall, affecting 19 residents. Noxious odors were noted, and an investigation revealed non-functioning exhaust systems in several rooms due to a broken belt on the motors. Maintenance checks were not conducted as required by facility policy.
The facility failed to provide dignified care to five residents, leading to feelings of frustration and low self-worth. A resident with a leaking ostomy bag was left soiled, another waited 30 minutes for repositioning assistance, and a third waited 27 minutes for bathroom help. Two residents with severe cognitive impairments faced undignified dining conditions, with one left out of reach of their meal. The DON acknowledged these issues, attributing them to staff behavior during the survey.
The facility failed to provide adequate ADL care for six residents, including assistance with personal hygiene and incontinence care. Residents were found soiled, unkempt, and without necessary grooming, with staff expressing being overwhelmed due to inadequate staffing. The facility's policy on regular checks and changes was not followed, leading to deficiencies in resident care.
The facility failed to provide appropriate respiratory care, including incorrect oxygen flow rates and lack of physician orders for some residents. Respiratory equipment was not properly maintained or stored, with nebulizers left uncleaned and undated. Some residents received oxygen therapy without documented physician orders, indicating systemic issues in respiratory care management.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.4% error rate. An LPN improperly broke an extended-release tablet for a resident with osteoarthritis, and an RN administered eye drops to a cognitively impaired resident without proper instruction. The DON confirmed the errors, which violated the facility's medication administration policy.
The facility failed to manage medication storage and labeling, resulting in expired and improperly dated medications on two medication carts. On the Maple Lane cart, a Novolin R FlexPen with an illegible date and expired Ibuprofen were found, while the Ivy Lane cart contained expired acetaminophen, nitroglycerin tablets, and undated Albuterol inhalers. The DON admitted the lack of a specific policy for medication dating and labeling, relying on a general policy and an undated document for guidance.
The facility failed to serve meals at appropriate temperatures, affecting two residents and the majority of a group meeting. Meals were delivered from the kitchen in an insulated cart, but food temperatures were below standard, with pancakes and scrambled eggs served at 98 to 106 degrees Fahrenheit. Residents reported dissatisfaction, with some resorting to ordering takeout. Despite attempts to address the issue, such as sending meals in waves, the problem persisted due to staffing challenges.
The facility failed to follow proper infection control practices during meal service and medication administration. A CNA delivered meal trays without hand hygiene or changing gloves, and contaminated ice was used. A resident with respiratory issues received medication via a nebulizer that was not properly cleaned. The medication cart was unsanitary, with personal items and uncovered food. Infection control policies were outdated, and corporate is responsible for updates.
A resident with a below-knee amputation and cerebral palsy was discharged from a facility to a hotel for three nights without a long-term plan, resulting in unsafe living conditions. The resident required wound care and one-person assistance but was discharged without necessary support or supplies. Facility staff were unaware of the resident's situation post-discharge, failing to follow the policy for a safe and orderly discharge.
The facility failed to provide written notification to two residents and/or their representatives regarding their transfer to an acute care facility. One resident with vascular dementia and acute kidney failure was hospitalized due to low blood pressure, while another with coronary artery disease, heart failure, and COPD was transferred due to septic shock and respiratory failure. The facility's policy requires written notice, but the DON stated that notification was done verbally unless an appeal was requested.
The facility failed to provide written bed hold notifications to two residents during hospital transfers. One resident with vascular dementia and acute kidney failure was hospitalized, and a blank Bed Hold Authorization form was uploaded to their EMR. Another resident with coronary artery disease and COPD was transferred due to septic shock, but there was no evidence of receipt of the bed hold policy. The facility's policy required written notification, but lacked a procedure to ensure compliance.
The facility failed to develop and implement comprehensive care plans for two residents with ostomy care needs, leading to potential unmet care needs. One resident was observed with a leaking ostomy bag due to a lack of specific care plan directives, while another resident experienced frequent leaks from an ileostomy bag without proper staff guidance on care frequency. The facility's policy on individualized interventions was not adequately followed.
A resident with COPD, Parkinson's, and an amputation was observed eating in a wheelchair angled away from the table, causing discomfort and difficulty in eating. The wheelchair was purposely dumped as a fall intervention, despite the resident's complaints and the risk of aspiration noted by the SLP. The facility's policy on resident rights was not upheld as the resident's preferences and comfort were not addressed.
A resident with a history of diabetes and amputation developed a stage three pressure ulcer due to inadequate interventions and care. Despite being at high risk, the facility failed to update wound care orders or provide sufficient incontinence care and repositioning. Observations revealed improper wound cleaning and reuse of a dirty sock, contrary to the facility's skin management policy.
A resident with COPD and nicotine dependence was found with cigarettes and a lighter, despite the facility's non-smoking policy. The resident, who used oxygen at night, was observed smoking outside the facility. Staff interviews revealed no smoking safety assessment was conducted due to the facility's non-smoking status, and the resident frequently signed out to smoke. This failure to enforce the policy and secure smoking materials led to the deficiency.
The facility failed to administer pneumococcal vaccinations to three residents despite having signed consents from their guardians. An interview with the Infection Preventionist/RN revealed a recent change in the vaccination offering process, now conducted quarterly. However, the facility's policy required vaccinations for residents over 65, and the oversight was identified during a record review.
A facility failed to train a non-licensed employee, Activities Aide B, with the State-approved course for feeding assistance. During a breakfast observation, the aide was seen feeding a resident requiring a mechanical soft diet, despite not being certified or trained. The DON confirmed only CNAs should provide such assistance, and the facility lacked paid feeding assistants. The aide's file showed no certification or training, and the job description did not include feeding duties, increasing the risk of feeding complications.
The facility failed to employ sufficient staff with the appropriate competencies in food and nutrition services. Observations revealed improper food temperature checks and incorrect portion sizes. Resident interviews highlighted complaints about small portions and poor food quality, indicating a lack of proper training and oversight.
The facility failed to provide written bed hold notices to five residents or their representatives during hospital transfers, as required by policy. The deficiency was confirmed through interviews and record reviews, revealing that notifications were made verbally over the phone without obtaining necessary signatures.
A resident with multiple diagnoses was discharged without a recapitulation of stay or discharge plan documented in their EMR. The Social Service Director and DON confirmed the omission, mistakenly believing it was unnecessary for transfers to another skilled nursing facility, contrary to the facility's discharge planning policy.
Failure to Review and Verify Medication Orders Results in Severe Medication Error
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician properly reviewed and verified medication orders for a resident admitted with multiple complex diagnoses, including cirrhosis, diabetes mellitus, hypertension, hypothyroidism, and Parkinson's disease. Upon admission, the resident's medication orders for Carbidopa/Levodopa and Levothyroxine were transposed, resulting in the resident receiving incorrect dosages and frequencies of both medications. The error was not identified or corrected by the admitting nurse, the physician assistant, or the physician, despite documentation indicating that the medication orders were outside the recommended dosing regimen and pending confirmation. The resident, who was ambulatory and able to care for themselves upon admission, experienced a significant decline during their stay. The medication administration record showed that the resident received multiple extra doses of Levothyroxine over several days, totaling 2800 mcg within a 96-hour period. Progress notes and interviews revealed that the resident became confused, disoriented, unable to ambulate, and exhibited signs consistent with thyroid storm, such as elevated temperature, tachycardia, and altered mental status. Family members and the medical examiner confirmed the resident's rapid deterioration and the facility's admission of the medication error. The review of the resident's records indicated that the transcription error was made by the RN/Unit Manager and confirmed by the same nurse. The physician assistant noted the need to confirm the dosing but did not discontinue or correct the erroneous orders. The medical director stated that the physician assistant should have changed the orders and that the pharmacist and nursing staff should have recognized the error, as Levothyroxine is typically administered once daily in the morning. The failure to properly review, verify, and correct the medication orders directly resulted in the resident's severe adverse effects and subsequent death.
Failure to Accurately Transcribe and Double-Check Admission Medications Resulting in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a newly admitted resident's medications were incorrectly transcribed and not properly double-checked according to facility procedures. The resident, who had a history of cirrhosis, diabetes mellitus, hypertension, hypothyroidism, and Parkinson's disease, was admitted for respite care and was ambulatory and alert at the time of admission. The hospital discharge orders specified Carbidopa/Levodopa to be given five times daily and Levothyroxine once daily, but these frequencies were transposed during the admission process. As a result, the resident received Levothyroxine five times daily and Carbidopa/Levodopa only once daily. Multiple staff interviews and record reviews revealed that the medication orders were entered by a unit manager and were supposed to be double-checked by a second nurse, but there was no documentation or confirmation that this double-check occurred. Several nurses and the pharmacist involved in the process either assumed the orders were correct or did not verify the original admission paperwork. The error persisted for several days, with the resident receiving excessive doses of Levothyroxine, totaling 2800 mcg over a 96-hour period. The facility's process lacked a formal policy or checklist for verifying new admission medication orders, and staff relied on informal practices that failed to prevent the error. The resident's condition deteriorated during the stay, with documented confusion, fever, tachycardia, and lethargy. The error was eventually discovered after the resident exhibited significant changes in condition, including increased confusion and abnormal vital signs. The facility's medical staff and hospice personnel confirmed that the medication error led to a thyroid storm, and the resident was discharged in a significantly worsened state, ultimately passing away at home shortly after discharge. The facility's documentation and interviews confirmed that the medication transcription error was not identified or corrected in a timely manner, and the required verification steps were not properly followed.
Failure to Identify and Correct Harmful Medication Dosing Error
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competencies in medication administration, resulting in a resident receiving harmful doses of thyroid medication. Upon admission, the resident had multiple diagnoses, including cirrhosis, diabetes mellitus, hypertension, hypothyroidism, and Parkinson's disease. The resident was ambulatory and able to care for themselves at the time of admission. However, due to a transcription error, the frequencies for Carbidopa/Levodopa and Levothyroxine were switched, leading to the resident receiving five times the prescribed dose of Levothyroxine for several consecutive days. Nursing staff did not identify the incorrect dosing parameters or recognize the resulting side effects. Progress notes indicated that the resident became confused, febrile, tachycardic, and lethargic, with abnormal vital signs and a need for oxygen. Despite these symptoms and the fact that the medication orders exceeded the usual dosing regimen, staff assumed the orders were correct, particularly because the resident was on hospice care. Interviews with nursing staff revealed that they did not verify the medication orders against the admission paperwork or question the unusual dosing frequency, instead relying on the assumption that the orders had been entered correctly. The facility's policy required nurses to verify medication labels against the medication administration record and to resolve any discrepancies before administering medication. However, this procedure was not followed, and the resident received a total of 2800 mcg of Levothyroxine within a 96-hour period. The resident's condition deteriorated significantly during their stay, and they expired at home the day after discharge from the facility.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, resulting in significant deficiencies in care. Multiple residents were left in soiled conditions for extended periods due to insufficient staff availability. For instance, one resident with a leaking colostomy bag was not attended to promptly, leading to soiling of the bed and clothing. The resident reported that staff were unable to change the bag during the night and had to wait until after breakfast service for assistance. This situation was exacerbated by a staff shortage due to a call-in, as confirmed by a registered nurse. Another resident activated their call light for assistance with repositioning in bed, but the call went unanswered for 30 minutes. During this time, staff were observed attending to other duties, such as meal service, indicating a lack of available personnel to address immediate resident needs. Similarly, another resident waited 27 minutes for assistance to use the bathroom, during which time they expressed discomfort and urgency. The delay was attributed to staff being occupied with other residents and a lack of coverage during staff lunch breaks. The report also highlights systemic issues with staffing levels, particularly on weekends and during evening shifts. The facility's staffing data revealed instances where the number of CNAs on duty was insufficient to meet the needs of the resident population, leading to delays in care and unmet needs. Interviews with staff and residents further corroborated these findings, with reports of long wait times for assistance and inadequate response to call lights. The facility's policies on staffing and care were not effectively implemented, contributing to the observed deficiencies.
Deficiencies in Food Storage and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during an initial kitchen tour. Expired and undated food items were found, including wilted cabbage, rotten potatoes, a broken raw egg, moldy cherry tomatoes, and undated vegetarian burger patties exposed to the environment. Additionally, hot dogs were found with an unclear use-by date. Culinary Aide W acknowledged the need for proper labeling and sealing of food items, while Dietary Manager Y confirmed that all foods should be labeled with a use-by date and discarded accordingly. The presence of visibly spoiled food and broken eggs was also noted as requiring immediate disposal. Furthermore, the cabinetry surrounding an ice machine in the main dining room was observed to be damaged and rotted, with Maintenance Director I confirming past issues with the ice machine leaking. The damaged cabinetry was acknowledged as needing replacement. These deficiencies in food storage and equipment maintenance had the potential to result in foodborne illness among the 89 residents in the facility, as per the FDA 2022 Food Code requirements.
Exhaust Ventilation Failure in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the exhaust ventilation system was functioning in resident bathrooms on the 300 Hall, affecting 19 out of 89 residents. This deficiency was identified through observations of noxious odors permeating the hall on two consecutive days. An investigation revealed that the exhaust systems in several bathrooms were not creating adequate negative pressure, as evidenced by a paper towel test. The rooms affected included 302, 303/304, 305, 306, 307/308, and 309. Interviews with the Maintenance Director and Maintenance Assistant revealed that the exhaust system motors were checked monthly, but the last check was reportedly conducted earlier in the month. The Maintenance Assistant discovered a broken belt on the motors responsible for the 300 Hall's exhaust ventilation, which had not been addressed since November due to the winter season. The facility's policy on maintenance requires the Maintenance Department to ensure proper functioning of ventilation systems, but this was not adhered to, leading to the deficiency.
Failure to Provide Dignified Care
Penalty
Summary
The facility failed to provide dignified and respectful care to five residents, resulting in feelings of frustration, humiliation, and low self-worth. Resident #37, who was cognitively intact, experienced a leaking ostomy bag that was not changed overnight, leading to soiled bedding and clothing. Despite the resident's request for assistance, staff delayed cleaning until after breakfast, leaving the resident in an undignified state. The facility's records did not indicate any refusal of care by the resident, contradicting staff claims. Resident #51, with mild cognitive impairment, activated the call light for assistance to reposition in bed. Despite the call light being illuminated and audible at the nurse's station, staff did not respond for 30 minutes, during which the resident was unable to eat comfortably. Similarly, Resident #7, with moderate cognitive impairment, activated the call light for assistance to use the bathroom. The resident waited 27 minutes for assistance, during which time staff failed to communicate the resident's needs to others before leaving the unit. Residents #38 and #2, both with severe cognitive impairments, were subjected to undignified dining conditions. Resident #38 was seated at a table with soiled meal trays and cups, while Resident #2 was placed out of reach of their meal and left without assistance. Despite attempts to reach the meal, Resident #2 was not aided by staff, resulting in spilled food. The Director of Nursing acknowledged the issues, noting that staff were not acting as usual due to the presence of surveyors and that housing soiled items on dining tables was unacceptable.
Inadequate ADL Care and Staffing Issues
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for six residents who required assistance with personal hygiene and incontinence care. Resident #35, who had severe cognitive impairment and required substantial assistance, was found soiled in urine and had not been checked on since 8:00 AM, despite being observed needing help at 11:56 AM. Similarly, Resident #36, also with severe cognitive impairment, was observed with unkempt hair, indicating a lack of assistance with personal grooming. Resident #42, who required total assistance for toileting and was frequently incontinent, was found lying in a urine-saturated soaker pad, causing skin irritation. The CNA responsible for their care had not checked on them since 3:00 AM, and the resident was left in this state until after breakfast. The CNA expressed being overwhelmed due to inadequate staffing, as they were the only CNA on duty with no additional help available. Resident #48, who required total assistance and was always incontinent, was also found in a similar state with a soiled soaker pad and bed sheets, and had not received care since the CNA's shift began at 7:00 AM. Resident #65, who required moderate assistance with personal hygiene, was observed with visible whiskers on her chin, indicating a lack of grooming. Resident #81, with severe cognitive impairment, was seen with disheveled and greasy hair, further highlighting the facility's failure to provide necessary ADL care. The facility's policy on ADL care, which includes regular checks and changes every two hours, was not adhered to, contributing to the deficiencies observed in the care of these residents.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by the lack of physician orders and improper administration of oxygen at prescribed flow rates. For instance, Resident #243 was observed with oxygen set at incorrect flow rates on multiple occasions, contrary to the physician's order of 2 LPM. Additionally, the portable oxygen tank was found empty, failing to provide the necessary supplemental oxygen. The facility's records inaccurately documented the administration of oxygen at the prescribed rate, and there were no orders allowing for adjustments in the flow rate. The facility also failed to ensure proper maintenance and storage of respiratory equipment. Several residents, including Resident #43 and Resident #88, had nebulizer equipment that was not stored with a barrier, was not dated, and was not cleaned appropriately after use. The nebulizer equipment was left assembled and exposed, increasing the risk of contamination. The Director of Nursing confirmed that nebulizers should be disassembled, rinsed, and stored in a bag, which was not adhered to in these cases. Furthermore, some residents were receiving oxygen therapy without a physician's order, such as Resident #3 and Resident #245. The facility did not have documented orders for these residents to receive supplemental oxygen, yet they were observed using oxygen concentrators. This lack of proper documentation and adherence to physician orders indicates a systemic issue in the facility's management of respiratory care, potentially compromising resident safety and care quality.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.4% error rate. This deficiency involved two residents. Resident #11, who was admitted with a primary diagnosis of osteoarthritis, had a physician's order for Tylenol 8 Hour Arthritis Pain Extended Release tablets. On a specific date, an LPN was observed breaking the extended-release tablet in half before administering it to the resident, contrary to the instructions that the tablet should be swallowed whole. The LPN justified the action by stating that the resident could not take a whole tablet. Resident #26, residing in a secured unit for cognitively impaired individuals and diagnosed with glaucoma, had a physician's order for Timolol Maleate Ophthalmic Solution. During medication administration, an RN was observed administering the eye drops in a dining room with other residents present, without instructing or assisting the resident to hold the lacrimal ducts to ensure proper absorption. The Director of Nursing confirmed that extended-release tablets should not be broken and did not provide a response regarding the proper administration of eye drops. The facility's policy on medication administration emphasizes accurate, safe, and sanitary practices, which were not adhered to in these instances.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly manage medication storage and labeling, leading to the presence of expired and improperly dated medications on two of the three medication carts reviewed. On the Maple Lane medication cart, a Novolin R FlexPen was found with an illegible date, and it was confirmed by an LPN that it was expired and needed disposal. Additionally, a bottle of ciprofloxacin eye drops was found with conflicting dates, raising concerns about its validity. An expired bottle of Ibuprofen was also discovered, and the LPN acknowledged the need for replacement. The LPN indicated that only certain medications, such as eye drops, insulins, and inhalers, were expected to be dated when opened. On the Ivy Lane medication cart, expired liquid acetaminophen and nitroglycerin sublingual tablets were found, along with three undated inhalers of Albuterol. The RN responsible for this cart confirmed the need to reorder these medications. The Director of Nursing admitted the absence of a specific policy for dating and labeling medications, relying instead on a general medication management policy and a document listing medications with shortened expiration dates. This document was used by nurses to determine the timeframe for using opened medications, but it was undated and not formally integrated into the facility's procedures.
Failure to Serve Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a palatable and appetizing temperature, affecting two specific residents and the majority of residents in a confidential group meeting. Observations revealed that meal trays were delivered from the main kitchen in an insulated cart, but the food temperatures were below the desired levels. For instance, pancakes and scrambled eggs were served at temperatures ranging from 98 to 106 degrees Fahrenheit, which is below the standard for hot foods. An Activities Aide reported that residents often complained about receiving cold meals, and the facility attempted to mitigate this by sending meals in waves, but staffing issues hindered timely delivery. Interviews with residents highlighted ongoing dissatisfaction with meal temperatures. One resident reported consistently receiving unappetizing meals due to cool temperatures and resorted to ordering takeout. Another resident confirmed the issue, stating that food temperatures were a frequent topic of concern in group meetings. Despite improvements in meal variety, the temperature issue persisted. During a confidential group meeting, eight out of nine residents expressed that meals were consistently served at unpalatable temperatures, with hot foods often arriving cool or cold. These concerns had been previously communicated to the Dietary Manager, but the problem remained unresolved.
Infection Control Deficiencies in Meal Service and Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during meal service and medication administration. Certified Nurse Aide (CNA) FF was observed delivering meal trays without performing hand hygiene or changing gloves between residents. Additionally, CNA FF handled a can of soda pop that had fallen into an ice chest with an ungloved, unwashed hand, and the contaminated ice was subsequently used by an Activities Aide. The facility's hand hygiene policy, effective 10/11/23, mandates hand hygiene before and after resident contact, which was not followed in these instances. Resident #88, who was admitted with acute respiratory failure and pneumonia, received medication via a nebulizer that was not properly cleaned or stored. Licensed Practical Nurse (LPN) O administered medication without assisting the resident with oral care or cleaning the nebulizer mouthpiece, which had been left on a bedside stand without a barrier. The nebulizer was not disassembled or rinsed as per the facility's procedure, which requires rinsing with sterile or distilled water and air drying. The facility's medication cart was also found to be unsanitary, with personal items and uncovered food containers placed on it. Registered Nurse (RN) A was observed drinking from a mug and placing it on the cart, alongside a cellular phone and an uncovered pudding container. The Director of Nursing confirmed that personal items should not be on medication carts and that hand hygiene is expected between resident interactions. Additionally, several infection control policies were outdated, with the Nursing Home Administrator and Infection Preventionist confirming that corporate is responsible for updating these policies annually.
Inadequate Discharge Planning for Resident with Amputation and Cerebral Palsy
Penalty
Summary
The facility failed to ensure a safe community discharge for a resident with a below-knee amputation and cerebral palsy, resulting in fear, distress, and feelings of helplessness. The resident was discharged to a hotel for three nights, paid by the facility, without a long-term discharge plan. The resident's insurance was supposed to cover his stay through October 2025, but the facility stated he no longer met the criteria for an insured stay. After the hotel stay, the resident had no place to go and ended up in a family member's travel trailer, which was not accessible for his wheelchair, leading to falls and further complications. The resident's medical record indicated he required wound care for his surgical site, but no formal wound care training or supplies were provided upon discharge. Interviews with facility staff revealed a lack of communication and planning for the resident's long-term accommodation needs. The Nursing Home Administrator and Director of Nursing were unaware of the resident's living situation after the hotel stay and did not provide adequate support or resources for his transition. The facility's policy on transfer and discharge requires sufficient preparation and orientation to ensure a safe and orderly discharge, which was not followed in this case. The resident's discharge plan indicated he needed one-person assistance for transfers, toileting, and bathing, yet he was discharged without the necessary support. The facility's actions and inactions led to the resident living in unsafe conditions without proper care or resources.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding the reason for their transfer to an acute care facility. This deficiency was identified for two residents. Resident #6, who was admitted with vascular dementia and acute kidney failure, was hospitalized due to low blood pressure. The facility's document titled 'Facility-Initiated Transfer for Nursing Homes' did not indicate a date of notification to the resident or guardian, nor did it have a signature. The Director of Nursing (DON) stated that the notification process involved verbal communication via telephone rather than written notice. Similarly, Resident #51, who had coronary artery disease, heart failure, and COPD, was transferred to the emergency room due to septic shock and acute hypoxic respiratory failure. The facility's transfer document noted the reason for transfer but lacked a signature from the resident or representative acknowledging receipt. The DON reported that written notice is only provided if an appeal is requested, and the reason for transfer and appeal rights are documented in the medical record. The facility's policy requires written notice of transfer or discharge, except in emergencies, where notice should be provided as soon as practicable.
Failure to Provide Written Bed Hold Notifications
Penalty
Summary
The facility failed to provide written notification of bed hold policies to two residents or their representatives during hospital transfers. Resident #6, who was initially admitted with vascular dementia and acute kidney failure, was hospitalized from November 19 to November 26, 2024. Although a blank Bed Hold Authorization form was uploaded to the resident's electronic medical record, the Business Office Manager confirmed that it was not the facility's practice to provide written notifications or obtain signatures, relying instead on verbal communication. Similarly, Resident #51, admitted with coronary artery disease, heart failure, and COPD, was transferred to the hospital on January 9, 2025, due to septic shock and acute hypoxic respiratory failure. The facility's transfer document indicated that the bed hold policy was included, but there was no evidence of the resident's or representative's receipt of this information. The facility's policy required written notification during admission and within 24 hours of hospital transfer, but it lacked a procedure to ensure this was done at the time of transfer.
Deficiency in Comprehensive Care Planning for Ostomy Care
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents with ostomy care needs, resulting in potential unmet care needs. Resident #37, who is cognitively intact and dependent on staff for activities of daily living, was observed with a leaking ostomy bag that was not being checked or emptied regularly as per any documented care plan directives. The resident's care plan lacked specific interventions regarding the frequency of checking and emptying the ostomy bag, as well as measures to address the frequent leakage issues. Similarly, Resident #12, who has moderate cognitive impairment and is dependent on staff for personal hygiene, reported frequent leaks from his ileostomy bag due to the facility using different supplies than he was accustomed to. The resident's care plan did not reflect the change in his ability to manage his ileostomy care, nor did it provide guidance on how often staff should check and empty the bag. The facility's policy on activities of daily living emphasized the need for individualized interventions and care plan updates, which were not adequately implemented for these residents.
Failure to Ensure Proper Positioning During Mealtimes
Penalty
Summary
The facility failed to ensure proper functional positioning during mealtimes for a resident with chronic obstructive pulmonary disease, Parkinson's disease, and an above-knee amputation. The resident was observed eating in a wheelchair that was angled away from the dining table, forcing him to balance his plate on his abdomen. This positioning was due to the wheelchair being purposely dumped as a fall intervention, which caused discomfort and difficulty in eating and swallowing. The resident expressed discomfort and difficulty reaching the table, and no assistance was provided to help him cut his food into manageable pieces. Interviews with the Director of Rehabilitation and the Director of Nursing confirmed that the wheelchair's positioning was intended as a fall prevention measure, despite the resident's complaints of discomfort and difficulty in maintaining an upright posture. The Speech Language Pathologist also noted that the reclined position could increase the risk of aspiration. The facility's policy on resident rights emphasizes the importance of self-determination and freedom of choice, which was not upheld in this case as the resident's preferences and comfort were not adequately addressed.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to implement appropriate interventions to prevent the development of a pressure ulcer for a resident with a history of hypertension, type two diabetes mellitus, and a below-the-knee amputation. The resident was admitted with a moderate risk for pressure sores, as indicated by a Braden scale score of 14, which later increased to a high risk with a score of 12. Despite this, the resident developed a facility-acquired, unstageable pressure sore on the left Achilles, which progressed to a stage three ulcer. The care plan for the resident included addressing skin integrity issues related to decreased mobility and diabetes with neuropathy. However, the physician's progress notes during the critical period lacked any mention of the pressure sore, and the wound care orders remained unchanged despite the worsening condition. Observations revealed that the resident was left in a saturated soaker pad, indicating inadequate incontinence care, and was not repositioned frequently enough, as confirmed by a CNA's statement. Further deficiencies were noted during wound care, where a nurse attempted to reuse a dirty sock after cleaning the wound, and the cleaning method was inadequate. The facility's policy on skin management emphasized the need for appropriate preventative measures and ongoing monitoring, which were not effectively implemented in this case. Interviews with staff confirmed these lapses in care, highlighting a failure to prevent the development and progression of the pressure ulcer.
Failure to Secure Smoking Paraphernalia for Resident
Penalty
Summary
The facility failed to ensure that smoking paraphernalia was stored securely for a resident with a history of chronic obstructive pulmonary disease (COPD), nicotine dependence, and chronic respiratory failure. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15/15, was observed with cigarettes and a lighter in his jacket pocket, despite the facility's non-smoking policy. The resident expressed frustration about having to leave the premises to smoke and was seen smoking in the roadway in front of the facility. The resident's electronic medical record included a physician's order for oxygen use at night, highlighting the potential risk associated with smoking. Interviews with facility staff revealed that a smoking safety assessment had not been conducted for the resident due to the facility's non-smoking status. The Licensed Practical Nurse (LPN) confirmed the resident's possession of smoking materials, and the Director of Nursing (DON) reiterated the facility's policy that residents should not have smoking paraphernalia. Despite the policy, the resident had signed out of the facility multiple times to smoke, as documented in the leave of absence binder. This oversight in enforcing the non-smoking policy and securing smoking materials contributed to the deficiency.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to maintain an effective vaccination program for three residents, as identified during a survey. The records for three residents revealed that although consents for pneumococcal vaccinations were signed by their guardians, the residents did not receive the vaccination boosters. This oversight was discovered during a record review, which showed discrepancies between the electronic medical records and the state immunization report. All three residents were noted to be over the age of 65, which places them in a high-risk category for serious complications from pneumococcal pneumonia. An interview with the Infection Preventionist/Registered Nurse (RN) D revealed that the facility had recently changed its vaccination offering process. Previously, vaccinations were offered yearly after a declination, but starting in January 2025, the facility began offering them quarterly. Despite this change, the facility's policy, dated November 2024, indicated that all residents over the age of 65 should receive the pneumococcal vaccine. The policy also required maintaining a log documenting the number of residents vaccinated, refused, or not vaccinated, and obtaining informed consent prior to vaccination. The failure to administer the vaccinations as per the signed consents and policy guidelines led to the deficiency.
Untrained Staff Providing Feeding Assistance
Penalty
Summary
The facility failed to ensure that a non-licensed employee, Activities Aide B, received the State-approved training course for feeding assistance to residents. During a breakfast observation, Activities Aide B was seen feeding a resident who required assistance with a level 3 advanced mechanical soft diet. When questioned, Activities Aide B stated that she was providing assistance because other staff were unavailable. The Director of Nursing confirmed that only Certified Nurse Aides are allowed to provide feeding assistance, and the Nursing Home Administrator verified that the facility does not employ any paid feeding assistants. A review of Activities Aide B's employee file revealed that she was not certified and had not completed the required State-approved training course for feeding assistance. This training includes essential skills such as feeding techniques, communication, safety procedures, and recognizing changes in residents' behavior. Additionally, the facility's job description for the Activity Aide position did not include feeding assistance as part of the essential functions and responsibilities. This oversight resulted in an increased risk of feeding complications for the residents requiring assistance during mealtimes.
Deficiency in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition services. During an interview, Dietary Cook (Staff) H admitted she had not completed the Certified Dietary Manager's (CDM) course work and relied on a CDM from another facility to help with tracking residents' weights. Observations revealed that Staff I was unable to bring tacos up to the required temperature of 135 degrees Fahrenheit and used improper methods to check the temperature. Additionally, Staff I incorrectly measured serving sizes, using a 4-ounce scoop for ham and potato casserole instead of the required 6-ounce serving size. The Nursing Home Administrator confirmed the absence of a full-time CDM at the facility. Further observations showed that Dietary Aide (Staff) J also failed to serve the correct portion sizes, using a 2-ounce scoop for collard greens instead of the required 4-ounce serving size. Resident interviews revealed complaints about small portion sizes and poor food quality, with one resident representative describing the food as often over or undercooked and portions varying significantly. These deficiencies indicate a lack of proper training and oversight in the facility's food and nutrition services, leading to inadequate meal preparation and serving practices.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to ensure written information was provided to five residents or their representatives regarding bed hold policies during hospital transfers. Specifically, the facility did not obtain signatures from the residents or their representatives on the Bed Hold Authorization forms for residents who were transferred to the hospital. This deficiency was identified through a review of progress notes, clinical census reports, and Bed Hold Authorization forms for five residents. In each case, the forms indicated that the resident or their representative was informed via telephone, but no written notice or signatures were obtained as required by the facility's policy. During an interview, the Accounts Receivable Manager confirmed that written notices were not issued and acknowledged that the bed hold policies were communicated verbally over the phone. The Nursing Home Administrator also acknowledged a system failure regarding the bed hold notifications. The facility's policy, revised on 2/14/22, mandates that residents or their responsible parties must sign the bed hold agreement, and these signed agreements should be part of the resident's business file. The failure to provide written notices and obtain signatures represents a clear deviation from this policy.
Failure to Complete Recapitulation of Stay for Discharged Resident
Penalty
Summary
The facility failed to ensure a recapitulation of stay was completed for a resident at the time of a planned discharge. The resident, who had diagnoses including bipolar disorder, major depressive disorder, suicidal ideations, and post-polio syndrome, was discharged from the facility without a discharge plan or recapitulation of stay documented in their electronic medical record (EMR). The Social Service Director and the Director of Nursing confirmed that no post-discharge summary was completed because the resident was transferred to another skilled nursing facility, under the mistaken belief that a recapitulation of stay was not needed for such transfers. The facility's policy on discharge planning, revised on 9/7/23, mandates that all planned discharges must include a completed post-discharge plan and summary by the interdisciplinary team. This includes a recapitulation of the resident's stay, a final summary of the resident's status at discharge, medication reconciliation, and a post-discharge plan developed with the resident's participation. The failure to follow this policy resulted in the deficiency noted in the report.
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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