Boulder Park Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlevoix, Michigan.
- Location
- 14676 West Upright, Charlevoix, Michigan 49720
- CMS Provider Number
- 235526
- Inspections on file
- 26
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Boulder Park Terrace during CMS and state inspections, most recent first.
The facility failed to maintain sufficient nursing staff to meet residents’ needs, resulting in frequent understaffing with as few as one or two CNAs for more than 40 residents, including many requiring incontinence care and two-person transfers. CNAs reported being unable to respond promptly to call lights, clear meal trays, or provide scheduled showers, and residents described long waits for assistance, prolonged periods in soiled briefs, and going more than a week without bathing. Review of shower records showed multiple residents without showers for 11–15 days, and one resident was observed with overgrown hair and beard, stating he had not showered in about two weeks and did not receive regular shaving help due to staff not having time. Staffing records documented numerous days with only one or two CNAs on duty despite a high census, and the facility assessment lacked clear, shift-specific staffing requirements for intermediate census levels, while leadership acknowledged ideal staffing levels but reported no specific contingency policy for call-ins.
The facility’s assessment of needed resources was incomplete, as it only identified staffing levels for census counts at or under 50 and for 63–68 residents in a 24-hour period, with no data for census levels between 51–62 or specific staffing needs by shift. The assessment also lacked a defined plan to maximize recruitment and retention of direct care staff and did not include a contingency staffing plan for non-emergency events that could affect resident care. The NHA acknowledged these gaps and confirmed there was no specific contingent staffing policy, relying instead on staff coming early, staying late, and lead nurses or management filling in on the floor.
Surveyors found that the facility failed to maintain adequate incontinence, catheter, and custodial supplies, leading staff to double-brief residents who preferred liners or chucks, cut up towels or use paper towels for perineal care due to a lack of washcloths, and improvise catheter setups when standard Foley bags were unavailable. A cognitively intact resident with urinary incontinence reported wearing two briefs because liners were out of stock, while another resident with CKD and an indwelling catheter reported missed monthly catheter changes and lack of preferred leg anchor bandages when catheter supplies ran out. Housekeeping staff reported running out of trash can liners, resulting in room trash with used briefs and wipes being emptied into a larger container without changing liners, leaving rooms odorous from soiled materials contacting unchanged trash bags.
A resident with a colostomy and parastomal hernia did not receive appropriate colostomy supplies when staff repeatedly used urostomy bags instead of correctly sized colostomy pouches, leading to fecal leakage and strong odors. A CNA reported that proper 38 mm colostomy bags had been unavailable for months, with only smaller 28 mm pouches in stock, and demonstrated having to rip urostomy bags to fit the stoma, which caused stool to clog the urine anti-reflux valve and back up. The DON, responsible for ordering supplies, initially stated the clear pouches were colostomy bags but later confirmed they were urostomy bags after observing care and an inventory showed only a partial box of 28 mm colostomy pouches. The resident, who values religious participation, reported embarrassment over the transparent, leaking pouch and associated odors and had previously voiced dissatisfaction with the current supplies.
A resident admitted with a sacral pressure ulcer did not have the hospital's wound care orders transcribed into the facility's records, resulting in the absence of documented treatment orders. Nursing staff provided wound care based on verbal reports rather than written orders, and changes in treatment were not formally documented until several days after admission.
The facility did not identify or address several critical areas—such as ABN, care plan updates, medication consents, abuse reporting, and PASARR—through its QAPI program. Issues within the MDS department contributed to these deficiencies, and the QAPI process failed to proactively recognize them before they were identified by surveyors.
Surveyors found that a medication room was repeatedly left unlocked due to a malfunctioning door, allowing unauthorized access when no staff were present. Inspections also revealed loose, unidentified pills in a medication cart and pharmacy totes containing discontinued and unreturned medications, including high-alert drugs, left unsecured in the medication room. Staff acknowledged the issues but were unsure why medications had accumulated or why the door remained unfixed, all in violation of facility policy requiring secure and orderly medication storage.
The facility did not provide required written notifications to residents regarding changes in Medicare and Medicaid coverage or the resulting changes in their financial responsibility. Several residents did not receive the appropriate SNF ABN form when their Medicare Part A services ended, and another resident was not informed in writing about changes to their Medicaid patient payment amount, leading to confusion and frustration.
The facility did not provide required written bed-hold policy information or transfer notifications to residents or their representatives when several residents were transferred to the hospital, nor did it notify the State LTC Ombudsman as required. Staff interviews and record reviews confirmed these omissions, which were attributed in part to busy conditions.
Due to insufficient staffing, multiple residents experienced missed showers, long wait times for assistance, and unmet personal hygiene needs. Residents and family members reported extended delays in call light responses and infrequent bathing, with some residents going weeks without a shower. Staff interviews and documentation confirmed that the facility did not consistently assign a replacement for the shower aide during absences, leading to significant gaps in care and resident frustration.
A resident with a diagnosis of bipolar disorder was admitted under a hospital exemption without a Level II PASARR, with the expectation of a short stay. When the resident became long-term, the facility failed to initiate the required PASARR II evaluation, and staff acknowledged the oversight, stating the process was not followed and the evaluation was not completed.
Two residents were admitted with significant medical needs—one with dysphagia and cognitive impairment, and another with a PICC line for IV antibiotics—yet baseline care plans addressing their high-risk conditions were not developed within 48 hours of admission, as confirmed by staff interviews and record review.
Two residents did not have comprehensive, person-centered care plans addressing their specific needs. One resident with a PICC line for IV antibiotics lacked a care plan focused on infection risks and line management, while another resident with a recent fracture and ongoing pain did not have care plan interventions for pain management or opioid monitoring. Nursing staff confirmed these omissions during interviews.
Two residents were administered psychotropic medications, including Haldol and PRN Xanax, without documented informed consent. Staff confirmed that no education or consent regarding the need, risks, benefits, or alternatives to these medications was present in the medical records, despite facility policy stating residents have the right to be informed about their treatment.
Staff served meals to residents on institutional trays in the dining rooms without removing plates and tableware, resulting in a meal service that residents reported was not similar to their home experience. Some residents, including those with moderate cognitive impairment and those cognitively intact, expressed dissatisfaction with this practice. The Certified Dietary Manager confirmed that staff do not consistently remove items from trays.
Two residents with severe cognitive impairment were involved in an incident where one resident groped another's breast in a common area, witnessed by staff. The victim attempted to defend herself and later expressed feelings of violation and distress. The perpetrator had a documented history of sexually abusive behaviors, and staff and family interviews confirmed the incident and its impact.
A resident with anxiety and intact cognition received a PRN antianxiety medication without documentation of specific anxiety-related behaviors or symptoms, and there was no evidence that non-pharmacological interventions were attempted prior to administration, contrary to facility policy.
Three residents were involved in an incident where a male resident with a history of sexually inappropriate behavior entered a room and inappropriately touched two female residents. Despite internal documentation and staff awareness of the incident, the facility did not report the abuse allegations to the State Agency as required by federal regulations.
Three residents were involved in an incident where a male resident with a history of sexually inappropriate behavior entered a room and touched two female residents under their blankets. Despite staff and administrator awareness of the event and prior documentation of similar behaviors, the facility did not conduct a required investigation into the abuse allegations, violating federal regulations and facility policy.
Surveyors found that required MDS assessments were not completed on time for four residents, including one whose death in facility assessment remained incomplete and three whose quarterly assessments were overdue. Nursing staff acknowledged missing the deadlines, and the NHA was unaware of the lapses.
Two residents with severe cognitive impairment were involved in a resident-to-resident abuse incident, where one resident groped another and the second responded physically. Despite documented behavioral symptoms and the witnessed event, care plans for both residents were not revised or updated with new interventions to address or prevent further incidents, as confirmed by the DON.
A resident with severe cognitive impairment and dementia exhibited frequent physical and sexual behavioral symptoms toward staff, including inappropriate touching and verbal aggression. Despite ongoing incidents documented in the medical record, staff interviews confirmed that no behavioral health assessment or intervention was provided, and the facility did not arrange for outside behavioral health services as required by policy.
The facility did not consistently document or follow up on pharmacy medication regimen review (MRR) recommendations for two residents, as required by policy. Although the EMR indicated that recommendations were made, the actual recommendations were missing from the records, and the DON was unable to provide them when requested.
A resident with a history of pain and psychiatric diagnoses received frequent PRN opioid medications without consistent documentation of pain assessments or attempts at non-pharmacological interventions prior to administration. The DON confirmed that facility practice required such documentation, but records showed this was not followed, and the facility's policy lacked guidance on opioid administration.
A resident with Crohn's disease and significant weight loss did not receive meals that accommodated their dietary preferences and medical needs, including a physician's order for double portions. The resident was served foods they could not tolerate and was not always provided with the required increased portions, due to incomplete dietary assessments and miscommunication among staff.
The facility failed to maintain adequate staffing levels, resulting in unmet care needs for residents. Two residents reported long call light response times and insufficient assistance, particularly for showers and bathroom needs. The Facility Assessment outlined specific staffing requirements, which were not met, and Resident Council meeting minutes consistently documented concerns about staffing. Interviews with the DON and NHA revealed a lack of awareness and explanation for these deficiencies.
The facility failed to provide prompt written responses to grievances for two residents, leading to frustration and feelings of being unheard. One resident submitted multiple complaints about food and other issues without receiving written responses, while another resident filed seven complaints about a loud neighbor, which were not properly documented or addressed. The facility's grievance policy requiring written responses within five days was not followed.
The facility failed to timely report a resident-to-resident altercation and the results of an investigation to the state agency. In one incident, a resident kicked another's wheelchair and used profanity, with the investigation summary submitted three months later. Another incident involved a resident yelling and swearing at another, which was not reported. The NHA acknowledged these reporting delays, contrary to the facility's Abuse Prevention Program policy.
The facility failed to investigate resident-to-resident altercations involving three residents. An incident between two residents was reported late, lacking interviews and follow-up observations. Another incident of a resident yelling and swearing was not investigated or reported. The facility's abuse prevention policy was not followed.
The facility did not post the required daily staffing information for direct care nursing personnel. Observations revealed that postings lacked the facility name and documentation of total and actual hours worked by nursing staff. A review of postings showed missing information, including total hours worked and census data. The DON was informed but did not provide an explanation.
A resident at high risk for falls was placed in a recliner with the footrest elevated, leading to a fall and a hip fracture. The LPN failed to perform a full assessment or follow physician orders for an x-ray, delaying treatment. The DON confirmed the LPN's negligence, resulting in their termination.
The facility failed to ensure the QAPI committee met quarterly with required members. The Medical Director or designee did not attend the 4/30/2024 meeting, and no attendance record was found for the 1/10/2024 meeting. Additionally, no meeting was held for the third quarter of 2023. The interim-NHA and DON were unable to locate the necessary QAPI documents, resulting in potential quality-of-care concerns for all 55 residents.
The facility failed to review resident rights with eight residents, leading to their lack of awareness and frustration. Staff N admitted to not reviewing these rights due to conflicts between residents during meetings, and the Nursing Home Administrator acknowledged the issue when informed.
The facility failed to provide adequate CNA staffing, resulting in delays in responding to call lights and potential adverse outcomes. Residents reported extended wait times for assistance, particularly during the night shift when only two CNAs were on duty. Staff interviews and call light logs confirmed these issues, highlighting the facility's inability to meet its own staffing guidelines.
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, resulting in the catheter drainage bag and tubing frequently being positioned incorrectly, either resting on the floor or placed above the bladder level. CNAs were observed mishandling the catheter bag, and the DON confirmed that such practices increase the risk of infection and cross-contamination.
A facility failed to assess a resident's capability for self-administration of medications. Despite the resident's cognitive intactness and multiple medical conditions, there was no order for self-administration. An LPN left the resident alone with medications without verifying intake or ensuring safety, and the DON confirmed no assessment was conducted, violating facility policy.
The facility failed to develop comprehensive care plans for two residents, leading to potential unmet needs. One resident experienced significant weight loss without a nutritional care plan, while another resident's activity preferences were not addressed despite moderate cognitive impairment and a long-term stay plan.
The facility failed to update care plans appropriately for two residents, resulting in care plans that did not reflect their needs. One resident experienced a fall with significant injuries, and the care plan was not updated to include new interventions. Another resident had a catheter-related pressure wound, and the care plan lacked necessary focus areas and interventions until the day of the surveyor's observation.
A resident with moderate cognitive impairment and multiple medical conditions experienced a worsening catheter-associated pressure injury due to the facility's failure to change and rotate the catheter securing device as ordered. The nurse did not document the wound's characteristics or measurements, and there were inconsistencies in the Medication Administration Record (MAR) and Treatment Administration Records (TAR). The Director of Nursing (DON) confirmed the wound began as a small tear from catheter dislodgement, but there was no proper documentation or assessments to track the wound's healing.
The facility failed to ensure timely physician response to MRR pharmacy recommendations and did not follow physician orders for a resident with multiple diagnoses, including GERD and dementia. The pharmacist recommended a decrease in pantoprazole dosage, which the physician agreed to after a delay, but the order was never implemented. The DON confirmed the MRR signed by the physician was never written as an order, and no facility policy on MRRs was provided during the survey.
The facility failed to follow up on routine dental services for a resident, resulting in the resident's diet being downgraded to a pureed diet. The resident's dentures were sent out for repair, but no follow-up appointment was made, leading to the resident continuing on a pureed diet due to poor communication between the dental office and facility staff.
The facility failed to ensure dignified care experiences for three residents. One resident was left on the toilet for 45 minutes during a shift change, another was exposed to her roommate during toileting, and a third was left uncovered and exposed to the view of other residents. The DON confirmed the importance of maintaining resident privacy and dignity during care.
Failure to Maintain Sufficient Nursing Staff Leading to Missed Care and Hygiene
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ care needs and ensure their safety, as evidenced by multiple staff and resident interviews, record reviews, and observations. A complaint to the State Agency reported that only two nurses were in the building when there should have been at least three, and that the DON, Infection Control Nurse, and Administrator were absent, leaving staff feeling they were “drowning” with no help. A CNA reported the facility was constantly understaffed, often with just two CNAs for a census of 50 or more residents, many of whom were incontinent, resulting in residents sitting in excrement longer than appropriate. Another CNA described “strangely low” staffing, with night-shift CNAs finding residents already asleep with dirty dinner trays still in front of them because day-shift CNAs lacked time to clear them, and noted that there were usually only two CNAs at night and sometimes only one, with travel CNAs occasionally walking out upon realizing they were the only CNA on duty. Review of daily staffing sheets from November through March showed 46 occasions with only two CNAs on duty and seven occasions with only one CNA, while the census ranged from 42–58 residents, 26% of whom required two-person transfers. Residents reported delays and missed care directly related to low staffing. One resident stated there were often only one or two CNAs working the entire building, leading to extended call light response times, prolonged periods in soiled briefs, and going over a week without bathing. Another resident, incontinent of urine, reported several nights with only one CNA on duty and estimated waiting an hour or more for assistance after activating her call light. A CNA confirmed that showers were frequently missed due to low staffing and explained that on a day when three CNAs were scheduled, one called in sick, leaving only two CNAs and making it “nearly impossible” to help residents shower. Review of the shower binder showed that several residents had not received showers for 11–15 days, and one resident had only one shower recorded for the entire month. One resident was observed with a long beard and overgrown hair and reported not having had a shower in about two weeks and not receiving regular shaving assistance, which staff attributed to lack of time. The facility assessment lacked specific staffing needs by shift and for census levels between 51–62, and the NHA acknowledged that ideal staffing would be three nurses and three CNAs at a minimum but stated that what the facility wanted and what it could obtain were different, and that there was no specific contingency policy for staff call-ins.
Incomplete Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to maintain a comprehensive facility-wide assessment that identified the resources necessary to care for residents competently during routine operations and emergencies. Review of the facility assessment dated 1/19/26 showed an incomplete staffing plan that only specified the number of staff needed for a census at or under 50 residents in a 24-hour period and for a census of 63–68 residents in a 24-hour period, with no data for census levels between 51–62 residents and no breakdown of specific staffing needs by shift. Further review showed the assessment did not include a plan to maximize recruitment and retention of direct care staff and did not establish a contingency staffing plan for events that do not trigger the facility’s emergency plan but could affect resident care. In an interview, the NHA acknowledged the lack of specific staffing needs by shift and census and confirmed there was no specific contingent staff policy, stating instead that personnel may come early or stay late and that lead nurses or management may help fill in on the floor.
Inadequate Supply of Incontinence, Catheter, and Custodial Products
Penalty
Summary
The deficiency involves the facility’s failure to maintain adequate supplies of incontinence products, urinary catheter components, and custodial items necessary for trash removal, resulting in care that did not align with physician orders or residents’ preferences and goals. A complaint to the State Agency reported limited supplies of briefs, wipes, chucks, panty liners, and trash bags. Multiple CNAs reported that the facility was frequently out of correctly sized briefs, liners, chucks, and washcloths, and that staff were directed to use reusable washcloths instead of disposable wipes due to plumbing issues, which led to an extreme shortage of washcloths. Night staff reported having to cut up towels or use paper towels for perineal care when washcloths were unavailable. A resident with urinary incontinence and an amputation below the right knee, cognitively intact and frequently incontinent per the MDS, reported wearing two briefs because the facility had run out of liners, which she preferred to use with a brief to avoid soaking the bed, and described this as not ideal. CNAs confirmed that several residents who were heavy wetters and preferred liners or chucks in addition to briefs were instead placed in two briefs due to the lack of liners and chucks. A facility-wide tour with housekeeping staff showed only 13 washcloths on one hall, none on two other halls, and no clean washcloths ready in laundry, despite the DON later indicating there was an unopened box of washcloths stored on a high shelf in the laundry room that had not been accessed. The facility also failed to maintain adequate urinary catheter supplies and custodial trash supplies. A CNA reported frequent shortages of colostomy supplies and correct urinary catheter components, and documentation showed that when a resident self-removed a Foley catheter, the facility was out of Foley bags, leading staff to use an 18F Foley with a leg bag instead. Another cognitively intact resident with chronic kidney disease, obstructive and reflux uropathy, benign prostatic hyperplasia, and an indwelling urinary catheter stated that there had been times catheter supplies ran out and his scheduled monthly catheter change could not be done, and that requested leg anchor bandages were unavailable. Housekeeping staff reported that the facility had completely run out of trash can liners during the prior week, requiring room trash to be emptied into a large trash without changing liners, leaving rooms with used briefs or wipes odorous due to soiled materials leaking onto unchanged trash liners.
Failure to Provide Appropriate Colostomy Supplies and Care
Penalty
Summary
The facility failed to provide appropriate colostomy supplies for a resident with a history of colon cancer, colostomy, and parastomal hernia, resulting in ongoing problems with ostomy management. The resident had a BIMS score indicating moderate cognitive impairment and a care plan goal that ostomy care would be managed appropriately and stool would not leak. A CNA reported that staff had been using urostomy bags on the resident’s colostomy site for months because the correct 38 mm colostomy pouches were not in stock, and only 28 mm colostomy pouches were available. During an observation of colostomy care, the resident’s transparent ostomy bag was nearly full of feces, with fecal matter leaking from the upper right portion of the stoma and a strong, noxious odor in the room. The CNA obtained a urostomy bag from the resident’s nightstand and demonstrated that the plastic had to be ripped to fit the resident’s stoma and that the bag contained an anti-reflux valve designed for urine, which the CNA stated became clogged with stool and led to backups and fecal leakage. The DON, who was responsible for ordering medical supplies, initially stated the clear pouches in use were colostomy bags and that the facility was working on obtaining opaque bags per the resident’s preference. However, when asked to oversee the colostomy care, the DON confirmed that the pouch in use was a urostomy bag and acknowledged that using a urostomy bag instead of a colostomy bag could restrict fecal flow and lead to backup, leakage, or infection. An inventory of the supply closet revealed only a partial box of 28 mm colostomy pouches, with no appropriate-sized colostomy bags available for the resident. The resident reported significant embarrassment related to the transparency of the pouch and the associated odors from leakage, stating that he had not previously experienced such issues with his colostomy and that he had requested a different type of pouch. He also reported that participation in religious services was very important to him but that he sat in the back and avoided socializing due to concerns about the appearance and smell of his colostomy bag.
Failure to Transcribe and Implement Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to accurately transcribe and implement physician orders for pressure ulcer treatment for a resident admitted with an active diagnosis of a sacral pressure ulcer, altered mental status, and osteoarthritis. The hospital discharge summary specified that Medihoney should be applied and covered with Mepilex daily to the sacral pressure ulcer. However, upon admission, the facility did not enter this pressure ulcer care order into the resident's order set. Documentation from the Director of Nursing (DON) indicated that the pressure ulcer was treated with Medihoney and Mepilex on admission, but no formal treatment order was found in the resident's records. Further review showed that on a later date, a Registered Nurse (RN) noted changes in the wound's condition and reported a change in treatment to Hydrogel and Mepilex after consulting with a Nurse Practitioner. Despite this, there was no documentation of a change order or any pressure ulcer treatment orders until several days after admission. Interviews with the DON and RN revealed that care was provided based on verbal reports rather than documented orders, and neither could locate the necessary treatment orders or explain the lack of documentation.
Failure to Identify and Address Key Deficiencies Through QAPI
Penalty
Summary
The facility failed to identify and address multiple areas of improvement through its Quality Assurance and Performance Improvement (QAPI) program. Surveyors identified five specific concerns that were not proactively recognized by the facility's QAPI process: Advanced Beneficiary Notification (ABN), care plan updates, medication consents, proper reporting of abuse, and Preadmission Screening and Annual Resident Review (PASARR). During an interview, the Nursing Home Administrator (NHA) acknowledged that while there were Performance Improvement Plans (PIPs) in progress for wound care and weight measurement, PIPs for ABN and medication consents were only initiated after these issues were brought up by the survey team. The NHA also reported ongoing issues within the MDS department, which impacted timely ABN issuance, effective care planning, PASARR coordination, and completion of medication consents. The NHA described that the Interdisciplinary Team (IDT) met daily to identify concerns and that staff could report issues to unit managers, IDT members, or the compliance officer, but there was no anonymous reporting mechanism. The NHA was unable to explain why the QAPI program had not previously identified the concerns found during the recertification survey. The lack of proactive, system-level interventions and failure to identify these deficiencies through the QAPI process placed residents at risk for harm.
Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors identified multiple failures in the facility's medication storage and security practices. The main medication room near the front entrance and administration offices was repeatedly found to have a malfunctioning door handle and lock, resulting in the room being left unlocked and unsecured on several occasions. Staff, including RNs and the DON, acknowledged the issue and stated that maintenance had attempted repairs, but the door continued to fail to latch and lock properly. During these times, the medication room was accessible to unauthorized personnel, and there were periods when no staff were present to monitor access. In addition to the unsecured medication room, an inspection of a medication cart revealed loose, unidentified pills in multiple drawers and a plastic bag containing a tube of prescription medication dated over a year prior. The LPN accompanying the surveyor stated that nurses are responsible for cleaning the carts and ensuring medications are not left loose or mixed, but acknowledged that such issues should not occur. Furthermore, the main medication room contained multiple pharmacy totes on the floor, filled with medications from discharged or deceased residents and discontinued prescriptions. These included high-alert medications such as vancomycin IV bags, immunization vials, antidepressants, injectable blood thinners, insulin pens, and lidocaine patches. The LPN was unsure why these totes had accumulated and reported that pharmacy typically picks them up nightly, but they had been present for several days. Facility policy requires all drugs and biologicals to be stored securely in their original containers, with proper labeling, and in locked compartments accessible only to authorized personnel. The policy also mandates that discontinued or outdated medications be returned to the pharmacy or destroyed, and that medication storage areas be kept clean, safe, and orderly. The observed practices, including unsecured storage areas, accumulation of unreturned medications, and improper handling of medication carts, were inconsistent with these requirements and contributed to the cited deficiency.
Failure to Notify Residents of Changes in Medicare/Medicaid Coverage and Financial Liability
Penalty
Summary
The facility failed to provide required notifications to residents regarding changes in Medicare and Medicaid coverage and the resulting financial liability for services not covered. Specifically, three residents whose Medicare Part A services had ended did not receive the appropriate Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, CMS-10055) as required. Documentation indicated that the correct form was not used due to a recent change in business office staff, and the new staff member had not been properly educated on the correct process. The Nursing Home Administrator confirmed that the facility had not provided the up-to-date SNF ABN notice to residents discharging from Medicare Part A services over the past year. Additionally, a review of another resident's records revealed that changes in Medicaid coverage, which affected the resident's monthly patient payment amount, were not communicated in writing to the resident. The business office coordinator acknowledged that the facility did not provide written notice of these changes, assuming that Medicaid would notify the resident directly. The resident, who was cognitively intact, expressed frustration at not being informed of the increased charges prior to receiving his monthly statement. The facility's failure to notify residents of changes in coverage and financial responsibility was confirmed through interviews and record reviews.
Failure to Provide Required Bed-Hold and Transfer Notifications
Penalty
Summary
The facility failed to provide required written documentation and notifications related to bed-hold policies and transfer notices for multiple residents who were transferred to the hospital. In several instances, residents were sent out to the emergency department due to acute changes in condition, such as confusion, altered mental status, and suspected appendicitis. Despite these transfers, there was no evidence in the medical records that the residents or their representatives received written information about the facility's bed-hold policy or written notification of the transfer. Additionally, there was no documentation that the Office of the State Long-Term Care Ombudsman was notified of the transfers as required. Specifically, staff interviews and record reviews confirmed that written bed-hold policies and transfer notifications were not provided at the time of transfer for the residents involved. Facility policy requires that residents and their representatives be informed in writing of bed-hold and return policies prior to transfer, and that the ombudsman be notified of such events. However, documentation and staff statements revealed these steps were not completed, with staff citing workload and busy conditions as reasons for the omissions.
Failure to Provide Adequate Staffing Resulting in Missed Care and Hygiene Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, resulting in missed showers, extended wait times for assistance, and unmet personal hygiene needs. Multiple residents, including those with significant medical conditions such as enterococcus bacteremia, neuropathy, traumatic brain injury, and incontinence, reported long delays in response to call lights and infrequent bathing. One resident stated that it took over 45 minutes for staff to respond to his call light, while another was unable to brush his teeth or access personal hygiene items due to lack of staff assistance. Family members and residents consistently reported frustration with the lack of timely care. Observations and interviews revealed that the facility's shower aide was frequently reassigned to floor duties due to staff shortages, resulting in residents missing scheduled showers. Documentation showed that some residents went weeks without a shower, with no records of refusals or alternative care being provided. For example, one resident received only a handful of showers over a three-month period, with gaps of up to 38 days between showers. The facility did not assign a replacement shower aide during the regular aide's absence, and therapy staff only provided showers to a limited number of residents during this time. Staff interviews confirmed that low staffing levels led to missed showers and delays in care. The Director of Nursing acknowledged that no replacement was scheduled for the shower aide during absences, and that therapy staff only assisted with showers for residents already receiving therapy. Group interviews with residents further corroborated that many did not receive showers for extended periods, particularly when the shower aide was on vacation. These failures resulted in residents experiencing feelings of frustration, helplessness, and anger, as well as observable declines in personal hygiene.
Failure to Complete Required PASARR II Evaluation for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a Level II PASARR (Preadmission Screening and Resident Review) evaluation was completed for a resident with a known diagnosis of bipolar disorder, a serious mental illness. The resident was admitted to the facility following a hospital stay under a PASARR hospital exemption, which allowed for admission without a Level II PASARR on the condition that the resident would require less than 30 days of nursing facility services. The exemption documentation specified that if the plan changed and the resident required a longer stay, the OBRA Office should be notified for appropriate follow-up. Despite the resident becoming a long-term resident after multiple admissions, the facility did not initiate a Level II PASARR evaluation as required. The MDS nurse acknowledged that the resident should have had a PASARR II completed due to the extended stay but stated that the process had not been followed and the resident "fell through the cracks." The facility did not have a PASARR II on file for the resident at the time of the survey.
Failure to Establish Baseline Care Plans for High-Risk Admissions
Penalty
Summary
The facility failed to provide appropriate baseline care planning for two residents upon admission, specifically neglecting to address high-risk focus areas. One resident was admitted with Parkinson's disease and dysphagia, and was found to have a BIMS score indicating cognitive impairment. Despite these conditions, there was no baseline care plan in place to address the resident's difficulty swallowing and associated high risk of choking. Another resident was admitted with a diagnosis of Enterococcus bacteremia and was receiving intravenous antibiotics via a PICC line. This resident was cognitively intact, but the care plan did not include a baseline focus on the management and risks associated with the PICC line, such as potential complications and infections. Interviews with facility staff confirmed that baseline care plans should have been established for both residents to address their specific high-risk needs. The facility's policy requires that care plans incorporate goals and objectives based on comprehensive assessments and that these plans be accessible to all disciplines. However, the absence of baseline care plans for these residents' critical conditions represented a failure to meet immediate care needs as required by facility policy and regulatory standards.
Failure to Develop Comprehensive Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents. One resident was admitted with a diagnosis of Enterococcus bacteremia and was receiving intravenous antibiotics via a PICC line. Despite being cognitively intact and at risk for complications and infections related to the PICC line, there was no comprehensive care plan completed for this resident. Interviews with nursing staff confirmed that a care plan should have been in place, particularly addressing the PICC line and associated risks. Another resident, admitted with a left ankle fracture and diagnoses including anxiety and schizophrenia, was experiencing almost constant pain and was receiving both scheduled and PRN opioid pain medications. The care plan for this resident did not include specific focus areas, goals, or non-pharmacological interventions related to pain management or opioid use, nor did it address monitoring for adverse effects of these medications. Staff interviews confirmed the absence of these critical care plan components, despite the resident's ongoing pain and frequent administration of opioid medications.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to two residents. One resident with moderate cognitive impairment and diagnoses including traumatic brain injury and bipolar disorder was receiving Haldol, an antipsychotic medication, without any documented informed consent in the electronic medical record. Staff interviews confirmed that no signed consent or documentation of education regarding the need, risks, benefits, or alternatives to the medication was present for this resident. The process for obtaining informed consent was described as a responsibility of providers and nursing staff, but audits by social services did not reveal any evidence of consent for the medication in question. Another resident, who was cognitively intact and had a diagnosis of anxiety, was prescribed Xanax on an as-needed basis, also without any documented informed consent in the medical record. The DON confirmed that no consents were obtained for either the Haldol or the PRN Xanax. Review of facility policies showed that while one policy addressed physician responsibilities regarding antipsychotic medication use, it did not include requirements for informing residents or their representatives about the need for the medication or its risks and benefits. Another policy stated residents have the right to be informed about their condition and treatment options, but this was not followed in these cases.
Failure to Provide Homelike Meal Service Environment
Penalty
Summary
The facility failed to provide a homelike environment for residents by serving meals on institutional trays in the dining rooms, rather than removing the items from the trays before serving. Observations on multiple occasions showed that staff consistently served breakfast and lunch to residents with plates, cups, and tableware left on service trays, both in the main and rehabilitation unit dining areas. Interviews with residents revealed that several did not feel the meal service resembled their experience at home, with one resident indicating moderate cognitive impairment and others being cognitively intact. The Certified Dietary Manager acknowledged that staff do not always remove items from trays as preferred.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to monitor and prevent resident-to-resident sexual abuse involving two residents, both of whom had severe cognitive impairment as indicated by their BIMS scores of 3 out of 15 and diagnoses of dementia and Alzheimer's Disease. On the date of the incident, one resident was observed groping another resident's breast while both were seated in a common area. Staff witnessed the incident, with the victim attempting to defend herself by repeatedly slapping the perpetrator's shoulder. The victim later reported feeling violated and upset, and her family member confirmed her distress following the event. Documentation and interviews revealed that the perpetrating resident had a documented history of physical and sexually abusive behaviors toward others, occurring every 4 to 6 days. Staff statements and facility records confirmed the sequence of events, including the immediate reactions of both residents and the staff's awareness of the incident. The facility's policy on abuse prevention was reviewed, which states residents' rights to be free from all forms of abuse, including sexual abuse. The Nursing Home Administrator acknowledged that sexual abuse had occurred during the incident.
Failure to Document Rationale and Non-Pharmacological Interventions for PRN Antianxiety Medication
Penalty
Summary
The facility failed to document specific behaviors, signs, and symptoms of anxiety that justified the administration of a PRN antianxiety medication for one resident. The resident, who was cognitively intact and had a diagnosis of anxiety, had an active physician order for PRN Xanax. On one occasion, the medication was administered with the reason documented as 'generalized, not feeling well,' but there was no documentation of the specific anxiety-related behaviors or symptoms that prompted the use of the medication. Additionally, the electronic medical record did not contain evidence that non-pharmacological interventions were attempted prior to administering the PRN medication, as required by facility policy. The Director of Nursing confirmed the absence of documentation regarding both the specific need for the medication and the use of non-pharmacological interventions. The facility's policy mandates that such interventions and their effects be documented as part of the care planning process.
Failure to Report Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to identify and report allegations of abuse involving three residents, as required by federal regulations. One resident, who was cognitively intact and recovering from a left ankle fracture, reported that a male resident entered her room uninvited, placed his hand under her blanket, and attempted to move his hand up her thigh. She resisted and called for help, after which the male resident moved to her roommate's bed and repeated similar behavior. The roommate, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was unable to answer questions about the incident. Both incidents were witnessed or reported to staff, and the nurse practitioner and guardians were notified, but the events were not reported to the State Agency as required. The male resident involved had a documented history of sexually inappropriate behavior toward both staff and other residents, including multiple incidents of inappropriate touching and comments in the weeks leading up to the event. Progress notes indicated ongoing behavioral issues, and the care plan included interventions to monitor and redirect the resident away from female residents. Despite these documented behaviors and the specific incident involving two female residents, the facility did not submit a report of the abuse allegation to the State Agency. Interviews with staff confirmed that the incident was reported internally to the Nursing Home Administrator, who stated that she did not report the event to the State Agency because she believed there was no physical contact. However, both the resident and a registered nurse confirmed that inappropriate touching had occurred. The facility's own abuse prevention policy required investigation and reporting of all abuse allegations within required timeframes, but this was not followed in these cases.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving three residents. One cognitively intact resident with a left ankle fracture reported that a male resident in a wheelchair entered her room uninvited, placed his hand under her blanket, and attempted to move his hand up her thigh. After she stopped him, the male resident moved to her roommate, who was severely cognitively impaired and dependent for all activities of daily living, and similarly reached under her blanket. The incident was witnessed by staff who responded to calls for help. The male resident involved had a documented history of severe cognitive impairment and repeated sexually inappropriate behaviors toward both staff and other residents, including multiple incidents of inappropriate touching and sexual comments. Despite this history and the specific incident involving two female residents, the facility did not conduct an investigation into the event as required by their abuse prevention policy. The administrator and staff confirmed awareness of the incident but acknowledged that no formal investigation was initiated. Documentation in the medical records and staff interviews confirmed that the incident was reported to facility leadership, and that the male resident's behaviors had been previously identified and care planned for monitoring and redirection. However, the lack of a thorough investigation into the specific allegations of abuse on the date in question constituted a failure to respond appropriately to alleged violations, as required by federal regulations and the facility's own policies.
Failure to Complete Timely MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed in a timely manner for four residents out of sixteen reviewed. Specifically, one resident's MDS assessment related to death in the facility was noted as 'in process' and had not been completed or submitted as required. For three other residents, quarterly MDS assessments were not completed within the required 120-day timeframe, with the assessments only being completed after the deadline had passed. During interviews, a registered nurse acknowledged that several resident assessments were late and had been missed, and that the team was unaware of the incomplete death in facility record for one resident. The nursing home administrator was also not aware that the required MDS assessments had not been completed on time for the affected residents. These findings were based on both record review and staff interviews.
Failure to Revise Care Plans After Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to revise care plans to address supervision and behavioral interventions following a resident-to-resident abuse incident involving two residents with severe cognitive impairment. One resident, diagnosed with Alzheimer's Disease, anxiety, and depression, and another resident with dementia, both scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The second resident exhibited physical behavioral symptoms toward others, including hitting, kicking, pushing, scratching, grabbing, and sexually abusing others every 4 to 6 days, as documented in the medical record. On a specific date, the second resident groped the first resident's breast, which was witnessed by staff. The first resident responded by repeatedly slapping the second resident's shoulder, stating that the action was to make the other resident stop. Despite this incident, a review of the care plans for both residents revealed that no new interventions or revisions were made to address the incident or to prevent recurrence. The Director of Nursing confirmed that no changes had been made to the care plans following the event.
Failure to Provide Behavioral Health Services for Resident with Severe Behavioral Symptoms
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with severe cognitive impairment and a diagnosis of dementia, who exhibited frequent and escalating physical and sexual behavioral symptoms directed toward staff and others. Documentation in the resident's medical record and progress notes detailed multiple incidents over several months, including inappropriate touching, grabbing, verbal aggression, and sexual advances toward staff during care and transfers. Despite these ongoing behaviors, there was no evidence that the resident received any behavioral health assessment or intervention from outside behavioral health services. Interviews with facility staff, including the Social Services Designee, NHA, LPN, and DON, confirmed that the resident had not been seen by behavioral health professionals, and staff were either unaware of or had not initiated referrals for behavioral support. The facility's own policy required the provision of behavioral health services as needed, but no such services were provided for this resident, as confirmed by staff statements and the absence of documentation in the medical record.
Failure to Document and Follow Up on Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure consistent follow-up and documentation of monthly medication regimen reviews (MRRs) for two residents. For both residents, the electronic medical record (EMR) indicated that pharmacy recommendations were made on specific dates, but there was no documentation or pharmacy report available in the EMR detailing what those recommendations were. This lack of documentation meant that the recommendations from the pharmacist were not accessible for review or follow-up by the care team. When questioned, the DON stated that recommendations from the pharmacy are typically received via email and that nursing staff are responsible for auditing charts to ensure follow-up on pharmacy recommendations. However, the DON was unable to provide the missing pharmacy recommendations for the two residents in question. The facility's policy requires that consultant pharmacist findings and recommendations be documented and filed in the resident's chart in an easily retrievable format, but this was not done for the affected residents.
Failure to Document Pain Assessments and Non-Pharmacological Interventions Prior to PRN Opioid Administration
Penalty
Summary
The facility failed to consistently document pain assessments and the use of non-pharmacological interventions prior to administering PRN opioid pain medications for a resident with a history of left ankle fracture, anxiety, and schizophrenia. The resident was cognitively intact and experienced almost constant pain, receiving both scheduled and PRN pain medications, including oxycodone and tramadol. Review of the medication administration records over a two-month period showed that oxycodone was administered 69 times and tramadol 35 times, but only four pain assessments were documented for each medication. There was no documentation of any non-pharmacological interventions attempted before administering the PRN opioids. The Director of Nursing confirmed that the facility's standard practice required nursing staff to attempt non-pharmacological interventions and document both the intervention and the result prior to administering PRN pain medication, as well as to complete a pain assessment before opioid administration. However, the facility's medication management policy did not include any process or information related to the administration of opioid medications, contributing to the lack of consistent documentation and assessment.
Failure to Accommodate Dietary Preferences and Orders for Resident with Crohn's Disease
Penalty
Summary
The facility failed to accommodate a resident's dietary preferences and medical needs, specifically for a resident with Crohn's disease, abnormal weight loss, and protein-calorie malnutrition. Despite a physician's order for double food portions and the resident's stated intolerances to certain foods such as processed meats, cheeses, fried foods, excess sugar, wheat flour, and regular milk, the resident was repeatedly served meals containing these items. The resident reported not being asked about his food preferences or intolerances and expressed ongoing hunger, noting that he did not always receive the ordered double portions. Observations confirmed that the resident received standard portion sizes and was not offered substitutes when served foods he could not eat. Interviews with facility staff revealed that the Certified Dietary Manager had not completed the required Nutritional Preferences Assessment for the resident, resulting in the resident's preferences not being reflected on meal tray cards. The Nursing Home Administrator acknowledged that staff misinterpreted the dietary order, leading to inconsistent provision of double portions. Facility policy required that diets be determined in accordance with resident preferences and that a tray identification system be used to ensure correct meal delivery, but these procedures were not followed in this case.
Staffing Deficiencies Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of its residents, as evidenced by interviews and record reviews. A resident reported a shortage of nurses and CNAs, leading to extended call light response times and unmet care needs, such as not receiving a requested shower. The resident's medical record confirmed the lack of a shower on a specific date, and the care plans did not document shower frequency preferences. Another resident expressed similar concerns about staffing shortages, particularly regarding delays in assistance for bathroom needs, which caused discomfort. The Facility Assessment documented specific staffing requirements, which were not met during the reviewed periods in July and November. Staffing sheets revealed that no shifts had adequate numbers of nurses or CNAs according to the Facility Assessment. Resident Council meeting minutes consistently documented concerns about call light response times, but these concerns were not addressed in the Department Response forms. Interviews with the DON and NHA highlighted a lack of awareness and explanation for the staffing deficiencies, despite the DON's involvement in the Facility Assessment updates.
Failure to Provide Written Responses to Resident Grievances
Penalty
Summary
The facility failed to provide prompt written responses to grievances for two residents, resulting in feelings of frustration and being unheard. Resident #36, who was cognitively intact with a BIMS score of 15, had submitted multiple complaints to the facility and the State Agency, requesting written responses that were never provided. The Social Services Director acknowledged receiving grievances but did not log them properly or provide written responses to the resident. The Certified Dietary Manager recalled a food-related complaint from Resident #36 but did not have a formal concern form, and the grievance was not logged appropriately. Resident #37, also cognitively intact with a BIMS score of 15, submitted seven complaints over a week regarding a loud resident. The Social Services Director admitted to not completing the grievance forms in a timely manner and was found filling in responses during the survey. The grievances lacked proper documentation, including dates of review by the Nursing Home Administrator and signatures. Resident #37 confirmed not receiving any written responses to her complaints. The facility's grievance policy stated that a written summary of the investigation results should be provided within five working days, but this was not adhered to. The lack of proper documentation and failure to provide written responses to grievances led to the citation, as residents felt their concerns were not being addressed adequately.
Failure to Timely Report Resident Altercations
Penalty
Summary
The facility failed to timely notify the state agency of a resident-to-resident altercation and did not report the results of an investigation in a timely manner for three residents involved in incidents of abuse. In one case, a facility-reported incident (FRI) was submitted to the state agency two days after a witnessed altercation between two residents, where one resident kicked the back of another's wheelchair and used profanity. The investigation summary for this incident was submitted three months later, which was a significant delay. The Nursing Home Administrator (NHA) acknowledged that the FRI should have been submitted within 24 hours and the investigation results within five days. Another incident involved a resident who began yelling and swearing at another resident in the activity room. The nurse on duty documented the incident but did not report it to the state agency. The NHA agreed that this incident should have been reported within two hours, with an investigation initiated and followed up with a five-day report to the state agency. The facility's Abuse Prevention Program policy, revised in December 2016, requires timely investigation and reporting of abuse allegations as per federal requirements, which was not adhered to in these cases.
Failure to Investigate Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate resident-to-resident altercations involving three residents. An incident between two residents was reported to the state agency, but the investigation summary was submitted three months later. The facility's administrator could not provide a complete investigation file, lacking interviews, witness statements, and follow-up observations. The incident report was not completed, and the administrator acknowledged the absence of necessary documentation, attributing it to the tenure of the previous administrator. Another incident involved a resident yelling and swearing at another resident, which was not investigated or reported to the state agency. The facility's policy on abuse prevention requires investigation and reporting of such incidents, but this was not adhered to. The administrator agreed that the situation should have been investigated and reported, indicating a failure to follow the facility's abuse prevention program.
Failure to Post Required Daily Staffing Information
Penalty
Summary
The facility failed to post the required daily staffing information for direct care nursing personnel. On 11/12/24, the daily nurse staff posting was observed to be incomplete, lacking the facility name and documentation of the total number and actual hours worked by licensed and unlicensed nursing staff for each shift. A review of staff postings from 11/1/24 through 11/13/24 revealed that none contained the facility name, and the forms did not include columns for actual hours worked. Additionally, the total hours worked for each category of nursing staff were left blank on multiple dates. A posting dated 11/04 did not document the census for the night shift. The Director of Nursing was informed of these deficiencies but did not provide an explanation for the missing information.
Failure to Prevent Fall and Provide Adequate Post-Fall Care
Penalty
Summary
The facility failed to implement appropriate interventions to prevent a fall for a resident identified as R601, who was at high risk for falls due to cognitive impairment and unsteadiness on feet. R601 had a history of falls, including one with a major injury. On the day of the incident, R601 was placed in a recliner chair with the footrest elevated, which was considered a restraint, and left unattended. This positioning led to R601 attempting to self-ambulate, resulting in a fall and a right hip fracture. The incident was compounded by inadequate post-fall care. After the fall, R601 was found on the floor by a CNA, who called for an LPN. The LPN did not perform a full head-to-toe assessment and instructed CNAs to move R601 back to bed without using a mechanical lift, contrary to proper post-fall procedures. The LPN also failed to follow through with the physician's order for an immediate x-ray, delaying the diagnosis and treatment of the hip fracture. Interviews with staff revealed discrepancies in the handling of the situation. The Director of Nursing confirmed that the LPN had placed R601 in the recliner and failed to complete necessary assessments and follow physician orders. The LPN's actions were deemed gross negligence, leading to their termination. The lack of proper supervision and failure to adhere to post-fall protocols directly contributed to the harm experienced by R601.
Failure to Meet QAPI Committee Requirements
Penalty
Summary
The facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members. Specifically, the Medical Director or designee did not attend the meeting held on 4/30/2024, and no attendance record was found for the meeting held on 1/10/2024. Additionally, no meeting was held for the third quarter of 2023, as confirmed by the Director of Nursing (DON) and the interim-Nursing Home Administrator (NHA H). The DON reported that information from the third quarter of 2023 was included in the October-December 2024 meeting on 1/10/2024, but no separate meeting was held for the third quarter of 2023. The interim-NHA H was new and unsure where the previous NHA kept the QAPI documents. Despite calling the previous NHA in the presence of the surveyor, the DON was unable to locate the necessary QAPI information for review. The missing attendance records and confirmation of meetings were not provided by the survey exit on 5/15/2024. The facility's QAPI plan, last reviewed on 8/22/2023, mandates that the QA Committee meet at least quarterly and include specific members such as the Director of Nursing Services, the Medical Director or designee, the administrator, the Infection Control and Prevention officer, and a pharmacy representative. The failure to adhere to these requirements resulted in the potential for quality-of-care concerns for all 55 residents in the facility.
Failure to Review Resident Rights
Penalty
Summary
The facility failed to review resident rights with eight residents, leading to their lack of awareness of these rights. During a group meeting, the residents expressed frustration and confusion about their rights, asking the surveyor to explain them. The resident council president confirmed that resident rights were not reviewed at the monthly meetings. Review of the resident council meeting minutes from the past three months showed no mention of resident rights, despite concerns related to dignified call light answering and missing items being raised. Staff N, who was present at these meetings, admitted to not reviewing resident rights due to conflicts between residents that prolonged the meetings. Staff N did not involve Social Services or nursing management to address these conflicts, which further disrupted the meetings and prevented the review of resident rights. The Nursing Home Administrator (NHA) acknowledged the issue when informed and planned to mail a copy of the residents' rights to their representatives and review them in the next resident council meeting. The facility's policy on resident rights states that residents must be informed of their rights in writing and in a language they understand, both at admission and during their stay. However, this policy was not followed, resulting in residents being unaware of their rights and experiencing undignified communication from staff when requesting assistance or timely care and medications.
Inadequate CNA Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate staffing of Certified Nursing Assistants (CNAs) to meet the needs of residents, resulting in delays in responding to call lights and potential adverse outcomes. Observations, interviews, and record reviews revealed that residents experienced frustration and extended wait times for assistance, particularly during the night shift when only two CNAs were on duty for the entire facility. This staffing deficiency was evident in the experiences of three specific residents and several others who reported similar issues during a group meeting with surveyors. One resident, who was cognitively intact, reported waiting too long for their call light to be answered, leading to incontinence. Another resident with moderate cognitive impairment also expressed concerns about insufficient staffing and the rushed demeanor of the aides. The facility's call light logs corroborated these complaints, showing multiple instances where residents waited over 20 minutes, and sometimes over an hour, for assistance. The facility's staffing records confirmed that there were often only two CNAs on duty during the night shift, which was significantly below the facility's own assessment of required staffing levels. Interviews with staff members, including CNAs and the Director of Nursing (DON), further highlighted the impact of low staffing levels. Staff reported feeling overwhelmed and unable to provide timely care, leading to residents being left wet or in the same position for extended periods. The DON acknowledged the staffing deficits and confirmed that the facility's current staffing levels did not meet the needs of the residents, particularly during the night shift. The facility's policy and assessment indicated that more CNAs were needed to ensure adequate care, but these guidelines were not being followed, resulting in significant delays in resident care and services.
Inappropriate Catheter Care Leading to Potential Infection Risk
Penalty
Summary
The facility failed to ensure appropriate care of an indwelling urinary catheter for a resident with moderate cognitive impairment and multiple diagnoses, including urinary retention and urinary tract infection. Observations revealed that the resident's catheter drainage bag and tubing were frequently positioned incorrectly, either resting on the floor or placed above the level of the bladder, which poses a risk of infection and backflow of urine. Certified Nurse Aides (CNAs) were observed placing the drainage bag on the resident's lap or hooking it under the wheelchair seat, allowing the tubing and bag to drag on the floor. Additionally, the dark blue cover used for the drainage bag only protected the sides, leaving the bottom exposed and in contact with the floor surface. The CNAs involved were unaware of proper catheter positioning techniques to prevent contamination and infection. Further observations with a Registered Nurse (RN) confirmed that the catheter drainage bag was often left on the floor, and the RN acknowledged that this practice increases the risk of cross-contamination and infection. The Director of Nursing (DON) reported that catheter tubing and bags should never touch the floor and mentioned an incident where the resident experienced urethral trauma due to the catheter becoming dislodged. However, no accident report was completed for this incident. The facility's policy on catheter care, last revised in September 2014, emphasizes the importance of keeping the catheter tubing and drainage bag off the floor and positioned lower than the bladder to prevent catheter-associated urinary tract infections, which was not adhered to in this case.
Failure to Assess Resident's Capability for Self-Administration of Medications
Penalty
Summary
The facility failed to properly assess the mental and physical capability of a resident (R42) for self-administration of medications. R42's electronic medical record indicated a BIMS score of 15/15, showing cognitive intactness, and had medical diagnoses including muscular dystrophies, congenital stenosis and stricture of the esophagus, dysphagia, and acute bronchitis. Despite these conditions, there was no order for self-administration of medications. During medication administration, an LPN left R42 alone with medications, including a nebulizer solution and gummy vitamins, without verifying if R42 had taken all her medications or ensuring her safety while swallowing them. The LPN typically waited 10 minutes before returning to check on R42, showing a lack of concern for potential swallowing difficulties or incomplete medication intake. The Director of Nursing (DON) confirmed that there was no assessment for self-administration of medications for R42. Interviews with R42 revealed that nursing staff often left her to drink her creatine and fiber mixture on her own and allowed her to self-administer her nebulizer treatment and gummy vitamins. The facility's policy stated that residents have the right to self-administer medications if deemed clinically appropriate and safe by the interdisciplinary team, which includes a specific skilled assessment. However, this assessment was not conducted for R42, leading to a failure in ensuring the resident's safety and adherence to the facility's policies.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, resulting in potential unmet needs. Resident R23, who was admitted with diagnoses including diabetes, neuropathy, and wound treatment, experienced significant weight loss over a period of time. Despite being cognitively intact and expressing concerns about weight loss, R23's care plan lacked nutritional goals or interventions to address the weight loss. The Certified Dietary Manager acknowledged the absence of a nutritional care plan and recognized the need for dietary goals and interventions, especially given R23's wound healing process and weight loss history. Resident R9, admitted with a fracture of the right femur and heart disease, was observed to have moderate cognitive impairment. During a room visit, R9 expressed a desire for more activity options, as he did not enjoy the available activities like Bingo. The Activity Director confirmed that there was no care plan for R9's preferred activities, despite the standard practice of having an activity care plan for each resident. R9 was initially admitted for rehabilitation but was now planned to stay long-term, yet his activity preferences were not addressed in his care plan.
Failure to Update Care Plans Appropriately
Penalty
Summary
The facility failed to ensure care plans were updated and revised appropriately for two residents, resulting in care plans that did not reflect the residents' needs. Resident #5, who had severe cognitive impairment and a history of repeated falls, experienced a fall that resulted in significant injuries, including a laceration on the upper right eyebrow, bruising, and a broken nose. Despite the incident, the care plan for Resident #5 was not updated to include new interventions, such as monitoring for tangled blankets, which was identified as a contributing factor to the fall. The Director of Nursing (DON) acknowledged that the care plan should have been updated but was not, contrary to the facility's policy on care plan revisions and fall prevention protocols. Resident #39 had a catheter-related pressure wound that began as a small tear in the urethral meatus due to the catheter tubing becoming entangled in his feet while self-propelling in his wheelchair. The wound care observation revealed a significant tear through the glans of the penis, and the catheter securing device lacked a date indicating when it was last changed. The DON confirmed that there was no incident report for the initial catheter dislodgement and that the care plan did not include any focus area, goal, or planned interventions related to the catheter-related pressure wound until the day of the surveyor's observation. This omission was contrary to the facility's policy on ongoing assessments and care plan revisions. Both cases highlight the facility's failure to adhere to its policies on care plan updates and revisions, resulting in care plans that did not adequately address the residents' current conditions and needs. The deficiencies were identified through interviews, record reviews, and direct observations, underscoring the importance of timely and accurate care plan updates to ensure resident safety and well-being.
Failure to Prevent Worsening of Catheter-Associated Pressure Injury
Penalty
Summary
The facility failed to provide appropriate care to prevent the worsening of a catheter-associated pressure injury for a resident with moderate cognitive impairment and multiple medical conditions, including urinary retention and generalized muscle weakness. The resident had an indwelling urinary catheter and was dependent on staff for lower body dressing. During an observation of wound care, a significant tear was noted on the resident's penis, and it was found that the catheter securing device had not been changed or rotated as per the physician's order. The nurse responsible for the wound care did not document the wound's characteristics or measurements, only noting that the care was completed per the order on the Treatment Administration Records (TARs). The catheter securing device was supposed to be alternated between legs weekly to offload pressure, but there was no documentation indicating when it was last changed or rotated, leading to potential worsening of the wound. Further review of the resident's Medication Administration Record (MAR) and TAR revealed inconsistencies in the documentation of catheter securing device changes. The device was not changed on the scheduled date and was recorded as changed two days later without proper documentation of the location. The resident's progress notes indicated that the catheter securing device was not rotated between legs as required, and there was no documentation of assessments or tracking of the wound's healing or progression. The Director of Nursing (DON) confirmed that the wound began as a small tear due to the catheter becoming dislodged and that there was no incident report or proper documentation of the trauma. The resident's electronic medical record (EMR) showed that the catheter securing device was changed on several occasions without recording the location, and there were no assessments or measurements of the wound to track its healing. The DON reported that the wound started as a small tear from the catheter dislodgement, but there was no documentation of this incident or subsequent assessments. The lack of proper documentation and adherence to physician orders led to the deficiency in providing appropriate care to prevent the worsening of the catheter-associated pressure injury.
Failure to Implement Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely physician response to Medication Regimen Review (MRR) pharmacy recommendations and did not follow the physician orders after they were written for one resident. Resident #5 (R5) had multiple diagnoses including GERD, dementia, diabetes, major depressive disorder, and chronic kidney disease. The pharmacist performed an MRR on 12/28/2023, recommending a decrease in pantoprazole dosage due to state guidelines and Beers criteria. The physician did not respond to this recommendation until 3/14/2024, agreeing to decrease the dosage, but the order was never implemented, and the pantoprazole remained at 20 mg daily. Subsequent MRRs on 1/20/2024 and 2/25/2024 did not identify any new irregularities, despite the initial recommendation not being addressed. The Director of Nursing (DON) confirmed that the MRR signed by the physician was never written as an order and expected the pharmacist's recommendations to be signed by the physician within one week. A facility policy on MRRs was requested but not provided during the survey, and the pharmacy procedure reviewed did not include the facility process or timeframe standards.
Failure to Follow Up on Dental Services
Penalty
Summary
The facility failed to follow up on routine dental services for a resident, resulting in the resident's diet being downgraded from a regular diet to a pureed diet. The resident, who had severe cognitive impairment and multiple medical conditions including complete loss of teeth, was observed eating a pureed diet during lunch rounds. The medical record indicated that the resident's dentures were sent out for repair, but there was no follow-up appointment made to ensure the dentures were returned in a timely manner. The Director of Nursing (DON) and the Business Office Manager acknowledged that the follow-up appointment was missed due to poor communication between the dental office and the facility staff. The resident's medical record showed that an impression of her mouth was taken by the dentist, and a follow-up appointment was scheduled but never made. Progress notes indicated that the resident's diet was downgraded to pureed due to spitting food out while waiting for the dentures. The care plan was updated to reflect this change, but the lack of a follow-up dental appointment led to the resident continuing on a pureed diet. The facility's policy on dental services stated that routine and emergency dental services should be available to meet the resident's oral health needs, but this was not adhered to in this case.
Failure to Ensure Dignified Care Experiences
Penalty
Summary
The facility failed to ensure dignified care experiences for three residents, leading to a deficiency in maintaining resident dignity. One resident, who had a stroke and required substantial assistance for toileting, was left on the toilet for approximately 45 minutes during a shift change. The resident became visibly upset and had to call his brother for assistance. The Director of Nursing (DON) confirmed the incident and noted that the call light system was not adequately responded to by the staff, leading to the prolonged wait time for the resident on the toilet. Another resident with severe cognitive impairment was observed being transferred to the bathroom with a sit-to-stand mechanical lift. The Certified Nurse Aide (CNA) left the bathroom door open, exposing the resident's buttocks and pubic area to her roommate. The CNA also cleansed the resident's genital area with the door open, compromising the resident's privacy and dignity. The DON acknowledged that all residents should be provided a dignified care experience, including covering exposed body parts and closing privacy curtains and window blinds. A third resident with moderate cognitive impairment and urinary issues was found lying in bed with an open incontinence brief and no covering, while the CNA walked away to perform hand hygiene. The resident expressed discomfort and coldness, and the room's window blinds were left open, exposing the resident to the view of other residents in the courtyard. The CNA later lifted the resident to a standing position with his pants down, further compromising his dignity. The DON reiterated the importance of maintaining resident privacy and dignity during care.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
