Beaconshire Nursing Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Detroit, Michigan.
- Location
- 21630 Hessel, Detroit, Michigan 48219
- CMS Provider Number
- 235475
- Inspections on file
- 31
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Beaconshire Nursing Centre during CMS and state inspections, most recent first.
Staff did not wear gowns while providing wound and peri care to a resident on Enhanced Barrier Precautions, despite clear signage and orders. The resident had multiple complex medical conditions, including an open wound and Foley catheter. Interviews confirmed staff were aware of the requirement to use PPE during high-contact care activities, but failed to do so.
Six residents were found without functioning call lights or alternative means to summon staff in their rooms. Staff confirmed that some call lights were not working and that desk bells were intended as a temporary solution, but several residents did not have these available. At the time of inspection, the affected residents were not in their rooms and did not voice concerns, and the NHA could not provide a list of malfunctioning call lights or a policy regarding call lights.
A resident with cognitive impairment and on blood thinners was found with multiple bruises, including a large bruise under the left breast, which staff failed to promptly report or investigate as required by facility policy. Despite staff observations and a CNA notifying a nurse, the bruises were not documented or reported until later, and the DON could not explain the delay or missing documentation in prior assessments.
The facility failed to cover desserts delivered to residents and did not maintain the ice machine in a sanitary condition. Meal trays with uncovered cheesecake were delivered to residents, and the ice machine was found with rust-colored substances and black speckles. Staff were unclear about cleaning responsibilities, with the Dietary Manager and Maintenance Supervisor providing conflicting information.
The facility failed to properly dispose of refuse and maintain cleanliness in garbage areas, potentially affecting all 92 residents. Observations revealed various trash items, including used gloves and cigarette butts, on the ground and in uncovered bins. The Maintenance Supervisor cited snow as a reason for some trash accumulation, but the facility's policy requires tightly fitting lids and cleanliness to prevent pest attraction.
The facility failed to effectively implement its QAPI program, leading to deficiencies in linen management and lab draws. The NHA identified linen availability as a concern but lacked consistent monitoring and documentation. Additionally, lab draws were not completed as ordered, with no evidence of evaluation in QA meetings. The facility's QAPI program lacked systematic documentation and data tracking, contributing to these deficiencies.
The facility failed to maintain sanitary conditions in the laundry room and clean linen closet, risking infection spread. Observations revealed uncovered clean linen carts, personal items on the floor, and soiled housekeeping carts stored improperly. The Housekeeping Supervisor and Nursing Home Administrator acknowledged these issues, which violated facility policies on infection prevention and linen handling.
The facility failed to maintain a proper air gap for the kitchen's three-compartment sink, risking contamination from sewage. Observations revealed a pipe leading to a floor drain with an inadequate air gap, surrounded by a black cover. The Dietary Manager was unsure of past sewage issues, while the Registered Dietician acknowledged the need for a proper air gap. The Maintenance Director confirmed the deficiency, and no further information was provided by the administration during the exit conference.
The facility failed to secure protected health information for two residents, leading to potential unauthorized disclosure. In one case, a laptop on a medication cart was left unlocked with a resident's EHR open, displaying sensitive medication information. In another instance, a resident's EMR was left open in a hallway, visible to passersby. Both incidents were acknowledged as HIPAA violations by staff.
The facility failed to maintain a safe and homelike environment, with deficiencies in room maintenance and bathroom facilities. In one room, a heating vent cover was removed and not replaced, leading to a cold environment. The maintenance log system was not effectively used, and the Maintenance Director was unaware of the issues. In another instance, a shared bathroom had a broken paper towel dispenser and an unstable sink supported by an orange construction cone. Housekeeping staff confirmed the long-standing issues, and the DON acknowledged the need for accessible paper towels.
The facility did not meet the required minimum square footage per resident in five rooms, with each room housing two residents but providing less than the required 80 square feet per resident. Despite this, no overt concerns were noted from resident interviews and observations. The Nursing Home Administrator and DON did not provide further documentation during the exit conference.
A resident with a history of COPD and moderate cognitive impairment suffered second-degree facial burns after unsupervised smoking while on oxygen. The incident occurred due to inadequate supervision by an untrained sitter, who allowed the resident to access smoking materials. The facility's failure to implement its smoking policy and ensure proper supervision led to the resident's injury.
A resident with COPD and moderate cognitive impairment sustained facial burns after lighting a cigarette while on oxygen. The facility failed to report the incident to the abuse coordinator or authorities, and staff initially believed the resident's claim of falling. The resident was hospitalized with second-degree burns, but the facility's records did not document the burns or the transfer. Interviews revealed a lack of communication and awareness among staff regarding the incident.
A resident with COPD and moderate cognitive impairment sustained facial burns after lighting a cigarette while on oxygen. Despite the resident's admission of the incident, the facility's records only mentioned a fall and redness, failing to document the burns. Staff interviews revealed inconsistencies, and the facility's policy on accurate documentation was not followed, compromising the resident's care.
A resident with quadriplegia and muscle wasting experienced pain and mild withdrawal symptoms due to the misappropriation of their prescribed Oxycodone. The medication, delivered and signed for by an LPN, was not administered on multiple days, and its disappearance was confirmed by the DON and pharmacy staff. The facility failed to implement its policy on preventing misappropriation of resident property.
A resident with quadriplegia and no cognitive impairment was prescribed Oxycodone for pain management. On one occasion, a 30-count of Oxycodone was delivered and signed for by an LPN but was reported missing. The resident informed the DON and physician, but the incident was not reported to the state agency as required by the facility's policy. Interviews confirmed the failure to report the missing medication, which is a deficiency in regulatory compliance.
A facility failed to properly reconcile controlled substances for a resident, potentially allowing drug diversion to go undetected. A resident with cognitive impairment had seven APAP Codeine tablets in the medication cart without proper documentation of removal. LPNs and the DON confirmed that narcotics should be signed out with date, time, count, and signature, which was not done. The facility's policy requires accurate reconciliation of controlled drugs.
A resident with moderate cognitive impairment and behavior issues was inadequately supervised, leading to their elopement through a second-floor window and sustaining severe injuries. The resident, initially in a first-floor room, was moved to a second-floor lockdown unit without guardian consent. Despite a care plan indicating the need for supervision, the resident had multiple falls prior to the incident. The facility's failure to provide adequate supervision and communicate with the guardian resulted in the resident's elopement and subsequent hospitalization.
The facility did not secure windows in the second-floor dining room and a resident's bathroom, allowing them to fully open and posing a safety risk. An LPN and the Maintenance Director confirmed the issue, and the Nursing Home Administrator acknowledged that the windows were not in compliance with the facility's policy, which restricts windows from opening more than six inches to prevent resident egress.
A resident with moderate cognitive impairment exited the facility through a window and was later found outside by an LPN. The resident was transported to the hospital, but the guardian was not notified of the room change to a lockdown unit or the hospital transfer, contrary to the facility's policy.
A resident exited a second-floor window and fell, sustaining multiple injuries. The incident was observed by an LPN, and the resident was transferred to the hospital. The facility failed to report the incident to the State Agency within the required timeframe, submitting the report four days later instead of within the specified two-hour window for serious injuries.
The facility failed to maintain comfortable room temperatures, with two residents experiencing discomfort due to excessive heat. Room temperatures ranged from 82 to 86 degrees Fahrenheit, exceeding the facility's policy. One resident, with respiratory issues, reported feeling extremely hot and requested an air conditioner without receiving a response. The Maintenance Director noted issues with air conditioning units, and the Nursing Home Administrator acknowledged the expectation for resident comfort.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to don appropriate personal protective equipment (PPE) while providing care to a resident on Enhanced Barrier Precautions (EBP). On the observed date, an LPN and a CNA performed wound care and peri care for a resident with an open wound and a Foley catheter without wearing gowns, despite an EBP sign posted on the door and orders in the resident's chart indicating the need for EBP. During the procedure, a unit manager also entered the room and did not observe the staff wearing gowns. Interviews with the involved staff confirmed their awareness that gowns should have been worn during high-contact care activities for residents on EBP. The resident involved had a history of urinary tract infection, osteomyelitis, a stage IV pressure ulcer, unspecified injury at C4, and neurogenic bowel, and was cognitively intact according to the most recent assessment. Facility policy required the use of PPE, including gowns, during high-contact care activities such as wound care and device care for residents on EBP. The Director of Nursing acknowledged that staff did not follow posted signs or physician orders regarding EBP during the incident.
Failure to Provide Working Call Light System or Alternatives in Resident Rooms
Penalty
Summary
The facility failed to ensure that a functioning call light system or alternative means of summoning assistance was available in the bathrooms and bathing areas for six residents. During an inspection, it was observed that one resident's private room did not have a call light cord plugged into the outlet, nor was there a desk bell or any other device to notify staff if assistance was needed. Staff members, including a CNA and an LPN, were unable to locate a call light or bell in the room. The nurse unit manager confirmed that some call lights were not functioning and that desk bells were supposed to be provided as a temporary measure, but acknowledged that this resident did not have one. Further inspection revealed that five additional residents also lacked call lights or any alternative means to alert staff in their rooms. At the time of observation, these residents were not in their rooms and did not report concerns about the missing call lights or bells. The Nursing Home Administrator stated that the facility was in the process of repairing the call light system and that all affected residents should have had a desk bell or similar device, but was unable to provide a list of malfunctioning call lights and confirmed there was no policy in place for call lights.
Failure to Timely Report and Investigate Bruises of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting and investigation of a bruise of unknown origin for one resident, as required by policy. The resident, who had multiple diagnoses including bipolar disorder, psychotic disorder with delusions, schizophrenia, and was on a blood thinner (Eliquis), was observed with bruises on both upper arms and a large purplish red bruise under the left breast. Initial observations and interviews revealed that staff, including LPNs and CNAs, were either unaware of the bruising or had not reported it according to protocol. The resident denied any abuse or pain and declined a full skin assessment initially, but later allowed for further examination, which confirmed the presence of the bruises. Despite the facility's policy requiring immediate investigation and reporting of suspected abuse or unexplained injuries, the bruises were not promptly reported or investigated. The DON confirmed that an investigation and report to the State Agency were only initiated after the issue was brought to their attention, and could not explain the delay or the lack of documentation in prior skin assessments. The facility's policy mandates reporting all alleged violations within specified timeframes, particularly for injuries of unknown origin or those in potential areas of abuse, such as the breast, but these procedures were not followed in this instance.
Uncovered Desserts and Unsanitary Ice Machine
Penalty
Summary
The facility failed to ensure that desserts delivered to three unidentified residents were properly covered during meal service. During lunch observations, meal trays with uncovered cheesecake desserts were delivered to residents in a dining room. The Dietary Manager confirmed that all food should be covered to prevent contamination, and the Nursing Home Administrator acknowledged that the food was supposed to be covered, questioning why the meal cart was not brought closer to the dining room. Additionally, the facility did not maintain the ice machine in a clean and sanitary condition. An observation revealed a rust-colored substance on the inside hinge of the ice machine's door and numerous black speckles on the ice dispenser's hood. The outside of the machine had drip stains of an unidentified substance. The LPN present could not identify the substances or the department responsible for cleaning the ice machine. The Housekeeping Supervisor stated that housekeeping was not responsible for cleaning the ice machine, while the Dietary Manager indicated that the dietary department was responsible for the outside and the maintenance department for the inside. The Maintenance Supervisor was unaware of the need for cleaning, relying on an outside company for biannual cleanings.
Improper Disposal of Refuse and Cleanliness Issues
Penalty
Summary
The facility failed to properly dispose of refuse and maintain cleanliness in the garbage and refuse areas, which could potentially harbor pests and affect all 92 residents. During an observation at the rear of the facility, various items such as plastic cups, paper, used gloves, and cigarette butts were found on the ground. Additionally, a wooden palette, electric fan cover, and a red storage container were propped against the building, with the red storage bin uncovered and containing used gloves, soiled linen, and trash. A large broken bed frame, used gloves, plastic soda bottles, and other trash were also observed near a back door. Further observations included eight plastic storage bins, some upright and some overturned, stacked against the wall near the rear door, surrounded by trash and debris. A container covered with a yellow tarp contained frozen standing water and trash, with a plastic lid on top and a rusted shovel and trash on the ground around it. Used gloves and straws were found frozen to the ground, and a large grey bin was filled with empty plastic bottles, milk cartons, plastic cups, pieces of plaster, and other trash, without a cover. The Maintenance Supervisor acknowledged the presence of trash and debris, attributing some of it to recent snow and stating that trash should not be placed on the ground. The facility's policy on garbage disposal emphasizes the need for tightly fitting lids on refuse containers and maintaining cleanliness to prevent pest attraction, which was not adhered to in this instance.
Deficiencies in QAPI Program and Linen Management
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by deficiencies in managing linen supplies and lab draws. The Nursing Home Administrator (NHA) identified linen availability as an area of concern, with a plan developed to ensure sufficient linen and staff for processing. However, the NHA was unable to provide data or documentation that the linen issue was consistently monitored or discussed in subsequent Quality Assurance (QA) committee meetings. Additionally, the NHA acknowledged that lab draws were not occurring as ordered, with seven out of 15 lab orders not completed as required in October 2024. Despite these issues, there was no evidence that the nursing concern was evaluated in the November 2024 QA meeting or subsequent meetings. The facility's QAPI program lacked systematic documentation and tracking of data, as required by its own policies. The NHA admitted that there was no report recapping QAPI activities or tracking of data, which is contrary to the facility's policy that mandates regular data collection and analysis. The facility's failure to maintain documentation and demonstrate evidence of its ongoing QAPI program, including the monitoring and evaluation of corrective actions, contributed to the identified deficiencies. During the exit conference, the NHA and Director of Nursing did not provide additional documentation or information to address these concerns.
Infection Control Deficiency in Laundry and Linen Management
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the laundry room and clean linen closet, which could potentially lead to the spread of infection and disease transmission among residents and staff. During observations, it was noted that the clean linen closet on the first floor had a folded gown and sheet on a dusty and dirty floor, a clean linen cart without a cover, and a heavily soiled sheet on the floor. Additionally, personal items belonging to an employee were found on the floor behind the clean linen cart. On a subsequent observation, used gloves, straws, plastic wrapping, and dust were found on the floor, and the clean linen cart remained uncovered. The Housekeeping Supervisor acknowledged that the linen closets should be cleaned daily and could not explain why the linen cart cover was on the floor. Further inspection of the facility's laundry service revealed that soiled housekeeping carts were stored in the washer/dryer room, which was in use, and clean linens were transported in a cart placed next to a soiled housekeeping cart. The clean linen room had uncovered bed sheets, resident blankets, socks, and clothes. The Housekeeping Supervisor agreed that clean linens should be covered when transported and stored, and that dirty housekeeping carts should not be stored in the laundry room due to the risk of cross-contamination. The Nursing Home Administrator also agreed with these observations. The facility's policies on infection prevention and control, laundry, and handling clean linen were reviewed, highlighting the requirement to handle, store, process, and transport linens in a manner that prevents contamination and infection transmission.
Improper Air Gap in Kitchen Sink
Penalty
Summary
The facility failed to ensure the proper air gap for the three-compartment sink in the kitchen, which is necessary to protect against contamination from sewage or other sources. During an observation, a pipe under the sink was noted to lead to a floor drain with a three-inch space between them, but a black cover was observed approximately 4-5 inches from the floor over the drain, surrounding the air gap. The Dietary Manager and Registered Dietician were questioned about the air gap, with the Dietary Manager unsure of any sewage backup incidents and the Registered Dietician acknowledging the need for a proper air gap to prevent contamination. The Maintenance Director later confirmed that the sink was not properly air-gapped. During the exit conference, the Nursing Home Administrator and Director of Nursing did not provide additional documentation or information.
Failure to Secure Resident Health Information
Penalty
Summary
The facility failed to secure protected health information for two residents, resulting in potential unauthorized disclosure. On the first occasion, a laptop on a medication cart in a commonly accessible hallway was left unlocked with the electronic health record (EHR) of a resident open, displaying sensitive information about their medication. The resident had a history of schizophrenia and moderate cognitive impairment. A Licensed Practical Nurse (LPN) acknowledged the violation of HIPAA regulations when questioned about the incident. In a separate incident, another resident's electronic medical record (EMR) was left open on a computer in a hallway, visible to passersby. A social worker noticed the open EMR and alerted a nurse, who confirmed the privacy breach. The resident involved had severe cognitive impairment and multiple diagnoses, including psychosis and vascular dementia. The Director of Nursing (DON) confirmed that leaving the EMR open was a violation of HIPAA protocols.
Deficiencies in Room Maintenance and Bathroom Facilities
Penalty
Summary
The facility failed to maintain a safe and homelike environment for residents in specific rooms, resulting in several deficiencies. In one room, the heating vent cover was removed and left propped against the vent, accumulating thick dust and dirt. Residents reported that the cover was removed during maintenance work on the heating system, but it was never replaced, leading to a cold room environment. Additionally, the plastic covering on the windows was removed by maintenance and not replaced, further contributing to the cold temperature. A small heating unit was present but was not effectively heating the room. The Maintenance Director was unaware of the ongoing issues, as residents had not reported them directly, and the maintenance log system was not effectively utilized. In another instance, the shared bathroom of certain rooms had a broken paper towel dispenser and an orange construction cone supporting the bathroom sink. The paper towel dispenser was non-functional, making it difficult for residents to access paper towels. The orange cone was used to stabilize the sink, which was at risk of dislodging. Housekeeping staff confirmed the long-standing issues with the bathroom facilities, and the Director of Nursing acknowledged that residents should have access to paper towels. The Maintenance Director admitted that the bathroom sink should have been fixed, indicating a lapse in maintenance oversight.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in five rooms, specifically rooms 111, 115, 119, 219, and 231. Each of these rooms housed two residents but did not meet the regulatory requirement of at least 80 square feet per resident. Rooms 111, 115, 119, and 219 were each 157 square feet, providing only 78.5 square feet per resident, while room 231 was 159 square feet, providing 79.5 square feet per resident. Despite these deficiencies, resident interviews and observations did not reveal any overt concerns related to the room size. During the exit conference, the Nursing Home Administrator and Director of Nursing did not provide additional documentation or information when asked.
Inadequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision for a resident on oxygen with a known history of unsupervised smoking and noncompliance with the smoking policy. This lack of supervision led to a fire incident where the resident sustained second-degree facial burns and required hospitalization in a burn unit. The incident occurred when an untrained facility staff member, acting as a sitter, failed to properly supervise the resident during a smoke break, allowing the resident to obtain a lighter and cigarette. Subsequently, the resident attempted to smoke in the bathroom while inhaling oxygen through a nasal cannula, resulting in the fire. The resident, who had a history of chronic obstructive pulmonary disease (COPD), schizophrenia, and moderate cognitive impairment, was admitted to the facility with a care plan that included specific interventions to prevent smoking-related incidents. Despite these measures, the resident was able to access smoking materials unsupervised, highlighting a failure in the facility's implementation of its smoking policy. Interviews with staff revealed that the sitter was not trained or authorized to supervise smoking, and the specific reasons for the sitter's presence were not communicated effectively. The facility's policy required that only trained staff, such as nurses, activities staff, and security personnel, supervise residents during smoking breaks. However, the sitter, who was not trained, took the resident out to smoke unsupervised, contrary to the facility's policy. This oversight, along with the failure to secure smoking materials, directly contributed to the incident, demonstrating a significant lapse in the facility's safety protocols and supervision practices.
Removal Plan
- The Director of Nursing/designee began an in-service with licensed nursing staff on independent smoker and dependent smokers, including resident choice of time smoking.
- All residents who smoke will be in-serviced by the Director of Nursing/designee on the smoking policy during a special resident council meeting to include the nonadherence to the policy that may result in revoking privileges and/or initiating a discharge plan care.
- Smoking signs were implemented asking families and visitors to not give residents smoking materials for the safety of our residents and turn in all smoking materials to be used only during scheduled smoking times.
- Staff was in-service on the updated smoking policy; to report any residents with smoking material immediately, staff includes security and sitters, and the updated policy includes reporting immediately to the charge nurse and management if any resident have any smoking materials and residents will be searched immediately.
- Unscheduled smoking times will not be permit without approval from administration. Residents that smoke will be offered a nicotine patch or offered to be taking out to smoke with a nurse or Cena.
Failure to Report Resident's Facial Burns from Smoking Incident
Penalty
Summary
The facility failed to report an incident of potential neglect involving a resident, identified as R401, who sustained facial burns after lighting a cigarette while on oxygen. The incident occurred on 11/10/2025, but the facility did not report it to the abuse coordinator or proper authorities. R401 was admitted to the hospital with second-degree burns to the face, lips, and nose, and required transfer to a burn center. Despite the severity of the injuries, the facility's records did not document the facial burns or the acute care transfer. R401, who has a history of COPD, schizophrenia, and moderate cognitive impairment, was observed with significant facial injuries during an interview at the hospital. The resident admitted to lighting a cigarette in the bathroom while on oxygen, which resulted in the burns. The facility staff, including LPNs and the sitter, initially believed R401's claim of falling in the bathroom, and no immediate action was taken to address the burns or report the incident as required by the facility's policy. Interviews with facility staff revealed a lack of awareness and communication regarding the incident. The Nursing Home Administrator and Director of Nursing were not informed of the true cause of R401's injuries until after the resident was hospitalized. The facility's policy mandates immediate reporting of such incidents, but this protocol was not followed, resulting in a failure to protect the resident's health and safety.
Failure to Document Resident's Facial Burns
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who sustained facial burns after lighting a cigarette while on oxygen. The incident occurred when the resident, who had a history of chronic obstructive pulmonary disease (COPD) and moderate cognitive impairment, lit his face on fire in the bathroom. Despite the resident's admission of the incident, the facility's documentation did not accurately reflect the occurrence of facial burns, as the records only mentioned a fall and redness to the face. Interviews with staff members revealed inconsistencies in the documentation and awareness of the incident. Licensed Practical Nurse (LPN) D and Sitter E, who were present during the incident, reported seeing redness but did not document burns. The resident's request to be transferred to the hospital due to pain was eventually honored, but the facility's records did not include a completed acute care transfer sheet, which would have documented the reason for the transfer. The Director of Nursing (DON) and other staff members acknowledged the resident's hospitalization for facial burns, yet the medical records lacked this critical information. The facility's policy on documentation requires accurate and complete records of residents' experiences and care. However, the failure to document the facial burns and the circumstances leading to the resident's hospitalization indicates a significant lapse in adhering to these standards. The absence of accurate documentation not only violates the facility's policy but also compromises the quality of care and safety of the resident.
Misappropriation of Resident Medication
Penalty
Summary
The facility failed to prevent the misappropriation of medication for a resident, resulting in the resident experiencing pain and potential withdrawal symptoms. The resident, who was admitted with quadriplegia and muscle wasting, had a scheduled pain medication regimen that included Oxycodone 30 mg to be administered every six hours. However, the Medication Administration Record for July 2024 showed that the medication was not given on multiple days. A delivery of 30 Oxycodone pills was made on July 18, 2024, and signed for by an LPN, but the medication was reported missing shortly after. Interviews with the resident, the Director of Nursing, the Pharmacy Manager, and the Pharmacy Driver confirmed the delivery and subsequent disappearance of the medication. The resident reported increased pain and mild withdrawal symptoms due to the missing medication. The facility's policy on abuse, neglect, and exploitation, which includes preventing misappropriation of resident property, was not effectively implemented, leading to this deficiency.
Failure to Report Misappropriation of Medication
Penalty
Summary
The facility failed to report allegations of misappropriation of medication for a resident diagnosed with quadriplegia and muscle wasting. The resident, who had no cognitive impairment and was on a scheduled pain medication regimen, was prescribed Oxycodone 30 mg to be taken every six hours. On July 18, a 30-count of Oxycodone was delivered and signed for by an LPN, but the medication was reported missing shortly after. The resident informed the Director of Nursing (DON) and the physician about the missing medication, but the incident was not reported to the state agency as required. Interviews with the DON, Unit Manager, and Nursing Home Administrator (NHA) confirmed that the missing narcotics were not reported to the state agency. The facility's policy mandates that any allegations of abuse, neglect, or misappropriation should be reported immediately, or within 24 hours if the events do not involve abuse or result in serious bodily injury. Despite this policy, the facility did not report the missing medication, which constitutes a failure to comply with regulatory requirements for reporting suspected abuse or misappropriation.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to properly reconcile controlled substances for a resident, identified as R102, which could potentially allow drug diversion to go undetected. During an observation and interview, it was found that R102 had seven tablets of APAP Codeine 300-30mg in the medication cart, but there was no proof of use record with dates, times, or signatures for medication removal. Licensed Practical Nurse (LPN) B admitted to counting the medication when removing it but not signing it out. This oversight was confirmed by interviews with LPN A and the Director of Nursing (DON), who both stated that narcotics should be signed out with date, time, count, and signature when removed from the medication cart. R102 was admitted to the facility with diagnoses including dementia and a fracture of the skull and facial bones. The Minimum Data Set (MDS) assessment indicated that R102 had significant cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 1 out of 15. Physician orders for R102 included Acetaminophen-Codeine Tablet 300-30mg to be administered as needed for pain. The facility's Pharmacy Services policy, revised on the date of the observation, mandates accurate reconciliation of controlled drugs, which was not adhered to in this instance.
Inadequate Supervision Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision for a moderately cognitively impaired resident with behavior issues, resulting in the resident exiting a second-floor window and sustaining serious injuries. The resident, who had diagnoses including schizophrenia and a left calcaneus fracture, was initially admitted to a first-floor standard room. The care plan indicated the resident was at risk for injury due to behaviors and impaired cognition, requiring supervision and cueing to maintain safety. Despite these interventions, the resident had multiple falls prior to the incident, indicating a pattern of inadequate supervision. On the night of the incident, the resident was moved to a second-floor lockdown unit without the guardian's permission or notification. The resident was placed in bed at 10:30 PM, but by 10:45 PM, the window was found open, and the resident was missing. The resident was discovered outside on the ground, having fallen from the window, and was subsequently transported to the hospital with severe injuries, including a collapsed lung and multiple fractures. The facility's policy on abuse, neglect, and exploitation emphasizes the need for trained and qualified staff to meet residents' needs and prevent neglect. However, the failure to provide adequate supervision and the unauthorized room transfer contributed to the resident's elopement and subsequent injuries. The guardian was not informed of the room change or the incident until contacted by the hospital, highlighting a communication breakdown within the facility.
Failure to Secure Windows Poses Safety Risk
Penalty
Summary
The facility failed to ensure the safety of residents by not securing windows in the second-floor dining room and a resident's bathroom from fully opening. During an observation with an LPN, it was noted that the bathroom window in a resident's room could be fully opened as the top pane did not lock, posing a safety risk. The LPN acknowledged that the window should lock and not open completely to prevent residents from exiting through it. Similarly, an observation with the Maintenance Director revealed that several windows in the second-floor dining room could also be fully opened, which the Maintenance Director confirmed could allow residents to exit the building. The Nursing Home Administrator stated that the facility's policy restricts windows from opening more than six inches to prevent resident egress and injury, acknowledging that the windows in question were not properly secured. The facility's Preventive Maintenance Program, revised in January 2024, is intended to ensure a safe environment, but the failure to secure these windows indicates a lapse in its implementation.
Failure to Notify Guardian of Room Change and Hospital Transfer
Penalty
Summary
The facility failed to timely notify the guardian of a resident, identified as R402, of an acute change in condition and did not obtain consent for a room change to a lockdown unit. The incident occurred when R402 exited the facility through a second-floor bedroom window and was later found outside by LPN C. The resident was then transported to the hospital. The clinical record indicated that R402 had moderate cognitive impairment and required substantial assistance for mobility. Despite having a guardian with the correct contact information, the guardian was not informed of the room change or the hospital transfer. The facility's policy on Notification of Changes requires informing the resident's representative of significant changes, including accidents and room changes. However, the guardian reported not receiving any notification from the facility about the room change or the hospital transfer. Instead, the guardian was informed by the hospital the following day. The facility's documentation and interviews revealed a lack of communication with the guardian, which is a violation of their policy.
Failure to Timely Report Elopement Incident
Penalty
Summary
The facility failed to immediately report an elopement incident resulting in injury to the State Agency. The incident involved a resident who exited a second-floor window and fell to the ground, sustaining multiple abrasions on the mid back, both legs, right hand, and right thigh. The resident was subsequently transferred to the hospital for further evaluation and treatment. The incident was observed by an LPN, who noted the injuries. The Facility Reported Incident (FRI) was submitted to the State Agency four days after the incident occurred, which was not in compliance with the facility's policy. According to the facility's policy on Abuse, Neglect, and Exploitation, such incidents should be reported immediately, but not later than two hours after the event if it involves serious bodily injury. The Nursing Home Administrator acknowledged that the FRI should have been submitted the day after the incident, indicating a failure to adhere to the specified reporting timeframes.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable room temperatures for two residents, resulting in discomfort and a decrease in their quality of life. Observations revealed that room temperatures ranged from 82 to 86 degrees Fahrenheit, exceeding the facility's policy of maintaining temperatures between 71 and 81 degrees Fahrenheit. Resident R303, who has medical conditions including Chronic Obstructive Pulmonary Disease and respiratory failure, reported feeling extremely hot and uncomfortable, stating that it felt like she was going to pass out. She had requested an air conditioner but had not received a response. Resident R302, who has quadriplegia and other medical conditions, also reported discomfort due to the heat in his room and other areas of the facility. The Maintenance Director acknowledged that the facility was in the process of replacing motors in air conditioning units, but the new units were not providing adequate cooling. Portable air conditioning units were being used as a temporary solution, but there were not enough available for all residents. The Nursing Home Administrator stated that resident comfort should be reported to operations and maintenance, and it is expected that residents do not feel uncomfortable. The facility's policy emphasizes maintaining safe and comfortable temperature levels, but the current situation indicates a failure to adhere to this policy, impacting the residents' comfort and well-being.
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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