Burcham Hills Retirement Center
Inspection history, citations, penalties and survey trends for this long-term care facility in East Lansing, Michigan.
- Location
- 2700 Burcham Drive, East Lansing, Michigan 48823
- CMS Provider Number
- 235236
- Inspections on file
- 31
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Burcham Hills Retirement Center during CMS and state inspections, most recent first.
A resident with hemiplegia and moderate cognitive impairment reported going days without showers and disliking the resulting odor, despite a documented preference for twice-weekly and PRN showers. Records showed the resident received only two bed baths over several weeks and did not receive a shower until weeks after admission, with no documented refusals. On one morning, therapy staff and an LPN found the resident saturated in urine, with clothing, linens, and the mattress soaked, and had to provide incontinence care. These events occurred despite a facility policy requiring appropriate assistance with hygiene and toileting for residents unable to perform ADLs independently.
A resident with left-sided hemiplegia, hemiparesis, and moderate cognitive impairment needed to have a bowel movement but could not locate the call light, which was sometimes placed on the resident’s weak side. The resident reported feeling around the bed with the functional arm but, unable to find the call light, attempted to get out of bed independently, slid to the floor, and fell. Documentation showed the resident was found on the floor beside the bed after calling out, had a bowel movement in bed, and was entangled in bedding and a PEG tube. A post-fall evaluation confirmed the call light was not activated, despite a care plan intervention requiring that the call light be kept within reach at all times, and an LPN later confirmed the resident could use the call light appropriately when it was accessible.
A resident with complex medical needs, including diabetes and a PEG tube for enteral feeding, did not consistently receive the prescribed amount of tube feeding due to pump malfunctions, inconsistent monitoring, and poor documentation. Staff failed to accurately record the volume of nutrition administered, leading to episodes of hypoglycemia and emergency interventions. Despite orders for regular checks and documentation, significant gaps and discrepancies persisted in the records.
Due to insufficient dietary staffing, several residents experienced significant delays in receiving their meals, with some waiting over an hour past scheduled meal times. Staff shortages led to the closure of a satellite kitchen, requiring meals to be served from other floors and further delaying service. Facility policies required adequate staffing for timely meal delivery, but these standards were not met, resulting in resident discomfort and dissatisfaction.
The facility did not ensure that food was served at safe and appetizing temperatures, as hot meal items were observed to be below the required temperature when delivered to a resident. Meals were transported in a non-insulated cart, and staff did not follow policies requiring inspection of food trays for temperature and palatability, affecting all residents who consume food products.
Surveyors found that food service equipment, including an ice machine and coffee maker, was not effectively cleaned and maintained, with visible residue and mineral deposits. Additionally, unopened milk with expired use-by dates was found in a kitchenette refrigerator, and not all potentially hazardous ready-to-eat foods were properly date marked according to facility policy. These deficiencies were confirmed through staff interviews and policy reviews.
Surveyors found that two outdoor waste receptacles had broken lids or panels, and miscellaneous debris including a wooden pallet, vinyl gloves, and paper products were left on the concrete pad near the dumpsters. Facility policy requires the area to be free of debris and for lids to be closed, but these standards were not met, affecting 105 residents.
Multiple residents and CNAs reported significant delays in receiving care due to inadequate nursing staff, with some shifts staffed by only one or two CNAs for entire units. Staff were also required to assist with meal service, further limiting their ability to provide direct care. As a result, essential care activities such as toileting, repositioning, and hygiene were not completed in accordance with residents' care plans.
An LPN failed to immediately report an allegation of resident-to-resident abuse to the NHA after receiving a call from a resident’s family member about a possible assault. The LPN did not observe injuries or receive a direct complaint from the resident and did not notify facility leadership. The NHA only became aware of the incident the following day, delaying the start of the investigation.
A resident with kidney failure and diabetes was transferred to the hospital, but the required discharge MDS assessment was not completed or transmitted within the mandated timeframe. Staff interviews confirmed that the responsibility for discharge MDS submissions was assigned to a specific nurse, and the assessment was overlooked.
A resident who was found unresponsive and transferred to a hospital, where they later died, was incorrectly coded on the discharge MDS as having gone home instead of being sent to an acute care hospital. MDS coordinators confirmed the error during interviews.
A resident requiring one-person assistance for bathing did not receive regular showers or baths, as evidenced by unkempt appearance and lack of documentation in the clinical record. The DON confirmed that showers should be offered twice weekly and refusals documented, but no records supported that hygiene care was provided or refused.
Two residents did not receive care as ordered, including missed doses of a prescribed diabetes medication and incomplete wound dressing changes. Documentation was lacking for the missed medication and wound care, and there was no evidence that the physician was notified or that required follow-up actions were taken by staff, contrary to facility policy.
A resident with a history of stroke and cognitive intactness was found with a cup containing six pills left unattended in their room. Although there was a physician order allowing staff to observe from a distance during medication administration, the DON confirmed the resident was not approved for self-administration. The nurse did not ensure the medications were taken as required, resulting in a failure to safely store and administer drugs according to facility policy.
The facility did not ensure that the Infection Preventionist, an RN, had completed the required specialized training in infection prevention and control, as neither the RN nor the DON could provide documentation of course completion, and no other staff member was overseeing the program.
A resident who required assistance with dressing was sent to an outside appointment wearing only a brief and covered with a sheet, without pants, coat, or hat, despite appropriate clothing being available in the room. The nurse involved reported feeling rushed and did not contact laundry for emergency clothing. The resident reported feeling cold and humiliated by the incident.
The facility failed to monitor the respiratory status of a resident with COPD, not following orders to maintain oxygen saturation levels and inconsistently assessing lung sounds during nebulizer treatments. Another resident with respiratory failure did not receive prescribed Budesonide due to unavailability, and the physician was not notified of missed doses. Staff interviews revealed a lack of adherence to protocols for respiratory care.
A resident exited the facility due to a lack of education for non-clinical staff on wander guards and alarmed doors. The resident, assessed as an elopement risk, left when the Admissions Director opened the door for visitors. The alarm sounded, but the director did not understand its significance. Interviews revealed inadequate orientation on elopement procedures for non-clinical staff.
Two residents experienced falls due to the facility's failure to follow care plans. One resident, with a history of falls and multiple medical conditions, suffered fractures after being transferred by a single CNA instead of the required two-person assist. Another resident, with Alzheimer's and a below-knee amputation, fell when a new CNA did not use the required EZ-Stand for transfers. The CNA involved was not adequately trained, as her personnel records showed no completed competency evaluation.
A resident with multiple medical conditions fell and sustained fractures due to improper transfer by a single CNA, contrary to the care plan requiring two-person assistance. The CNA was unaware of the requirement and had not completed a competency evaluation. The Nursing Home Administrator failed to report the incident as potential neglect to the State Agency.
A resident with multiple health issues, including a history of falls, suffered fractures after a fall during a transfer at a facility. The transfer was conducted by a single CNA, contrary to the care plan's requirement for a two-person assist. The CNA was unaware of this requirement and had not completed a competency evaluation. The incident was not immediately investigated or reported as neglect, indicating a deficiency in the facility's response.
The facility failed to ensure that five CNAs had completed the required competency evaluations necessary to care for residents. Despite working independently, the CNAs' personnel records did not demonstrate completed evaluations upon the completion of their orientation. Interviews with the Human Resource Director and Nurse Educator confirmed the absence of these evaluations, indicating a lapse in the facility's process for ensuring staff competency.
The facility failed to prevent the development and worsening of pressure ulcers for three residents, resulting in multiple facility-acquired pressure ulcers. Preventive measures were not consistently implemented, and there was a lack of communication and adherence to care plans, leading to the development of stage two and three pressure ulcers.
The facility failed to prevent recurrent falls and provide adequate supervision for two residents, resulting in head lacerations requiring emergency care. Both residents experienced falls shortly after admission, with delays in staff response and insufficient fall prevention measures. The facility's design and staffing issues contributed to the lack of timely assistance and supervision.
The facility failed to clean and maintain food service equipment, affecting 88 residents. Observations revealed soiled TurboChef oven and juice machine, a leaking vegetable preparation sink faucet, and a weak overhead spray arm spring. These issues violated the 2017 FDA Model Food Code and the facility's own maintenance policies.
The facility failed to effectively clean and maintain the physical plant, affecting 88 residents. Issues included soiled ventilation grills, damaged surfaces, and loose or missing vinyl base coving in various areas. The facility's maintenance work order system did not have specific entries related to these concerns, indicating a failure to adhere to the maintenance policy.
A resident with a PICC line had a dressing that was not changed within the required 48-hour period, leading to visible swelling and a blood-stained dressing. Staff interviews confirmed that the dressing should have been changed to assess the insertion site for signs of infection, but this was not done, increasing the likelihood of infection.
The facility failed to ensure that a resident received an assessment for meal consumption assistance and sufficient food intake, resulting in significant weight loss. Despite being noted as independent for eating, the resident was often found sleeping during meal times with untouched meals and nutritional supplements. Staff interviews and observations confirmed that the resident was not adequately monitored or assisted during meal times, leading to a 20.55% weight loss over a few months.
The facility failed to ensure sufficient nursing staff to meet resident needs, resulting in repeat falls and injuries for two residents. One resident experienced a fall three days after admission, leading to a head laceration, while another resident had two falls within a short period, both causing head lacerations. The facility's design and staffing levels were cited as contributing factors.
The facility failed to ensure that the attending physician documented and addressed the pharmacist's medication review recommendations for a resident with Alzheimer's, schizophrenia, and major depressive disorder. Recommendations to adjust medication doses and obtain a fasting lipid panel were not properly documented or acted upon, as confirmed by the DON.
The facility failed to adequately monitor a resident on risperidone for schizophrenia, despite recommendations from the pharmacist to obtain a fasting lipid panel. The last lipid panel was conducted over a year ago, as confirmed by the DON.
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. An LPN administered bisacodyl without a physician's order and failed to administer a prescribed probiotic and loperamide to a cognitively intact resident. The LPN reported the medications were not in stock, although the probiotic was documented as administered. The resident experienced loose stool/diarrhea later that day. The DON confirmed that probiotics were kept as a stock medication.
The facility failed to offer pneumococcal immunizations per CDC recommendations for two residents. Despite consent being given in November 2022, both residents did not receive the recommended dose of PCV15 or PCV20 at least one year after their last dose of PPSV23. The Infection Preventionist confirmed the oversight.
The facility failed to offer an updated COVID-19 vaccine to a resident with Parkinson's Disease, hypertension, and obstructive sleep apnea. The resident, who was cognitively intact, had not received a COVID-19 vaccine since 1/16/23, and there was no documentation of consent or declination for the updated 2023-2024 vaccine. The Infection Preventionist confirmed the oversight.
Failure to Provide Adequate Bathing and Timely Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), specifically bathing and timely incontinence care, for one resident. The resident was admitted and later readmitted with hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, and had a BIMS score indicating moderate cognitive impairment, yet was able to converse and answer questions appropriately. The resident reported going days without showers, disliking the resulting body odor, and stated a preference for two showers per week with additional showers as needed. The task list reflected this preference for showers twice weekly and PRN. However, record review showed the resident received only bed baths on two dates in February and did not receive a first shower until several weeks after admission, with the next shower not occurring until early March. There were no documented shower refusals in the electronic medical record. The deficiency also includes failure to provide timely incontinence care. A progress note documented that on one morning in February the resident and bed were soiled with urine while the resident was in bed requesting to get out of bed. Therapy staff reported finding the resident “pretty saturated in urine,” with urine soaking through clothing, bed linens, and down to the mattress, and they notified nursing and assisted with incontinence care. An LPN confirmed entering the room that morning to assist therapy staff and verified that the resident was saturated in urine through clothing and bed linens. These findings occurred despite a facility policy on ADLs stating that appropriate care and services, including support and assistance with hygiene (bathing) and elimination (toileting), would be provided for residents unable to carry out ADLs independently.
Failure to Ensure Accessible Call Light Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent a fall by ensuring a resident’s call light was within reach and that adequate supervision was provided. The resident had hemiplegia and hemiparesis affecting the left non-dominant side and was moderately cognitively impaired, scoring 9 out of 15 on the BIMS. The resident reported that staff sometimes attached the call light to his left side, where he had weakness and immobility. On the day of the fall, the resident needed to have a bowel movement but could not locate the call light despite feeling around the bed with his right arm. Unable to find the call light in time, the resident attempted to get out of bed independently to reach the bathroom, slid out of bed, and fell to the floor. Progress notes and incident documentation for the fall showed that the resident was found on the floor beside the bed after calling out for assistance, having had a bowel movement and attempting to get out of bed when he fell and hit his head. The resident was observed entangled in bedding and a PEG tube and was noted to be alert and oriented to baseline. The post-fall evaluation documented that the resident did not have the call light activated at the time of the fall. The resident’s fall care plan included an intervention to ensure the call light was within reach at all times. An LPN who was working that night reported hearing someone yelling, finding the resident on the floor, and confirming that the resident stated he had to use the bathroom and had a bowel movement in bed. The LPN also stated that the resident was able to use the call light appropriately when he had care requests.
Failure to Properly Manage and Document Feeding Tube Administration
Penalty
Summary
The facility failed to properly manage and document the administration of feeding tube nutrition for a resident with multiple complex medical conditions, including type 2 diabetes, dysphagia, functional quadriplegia, and dementia. The resident had a PEG tube for enteral feeding, with physician orders specifying the type, rate, and total volume of nutrition to be administered, as well as instructions for tubing changes and documentation. Observations and record reviews revealed that the prescribed feeding regimen was not consistently followed, with documented amounts of nutrition administered frequently above or below the ordered total, and numerous instances of missing or inconsistent documentation regarding the volume infused. There were multiple occasions where the feeding pump malfunctioned or was not properly monitored, resulting in the resident not receiving the required nutrition. This led to episodes of hypoglycemia, as evidenced by low blood sugar readings and the need for emergency interventions such as oral glucose and glucagon administration. Staff interviews confirmed that there were issues with the feeding pump not functioning correctly, and that staff had not received recent education on the use of feeding tube pumps. Additionally, documentation practices were inconsistent, with repeated or decreasing totals recorded and significant gaps in the required two-hourly documentation of infused amounts. Nursing management and the DON were made aware of the issues after family concerns and direct observations of the resident not receiving the correct amount of feeding. Despite the implementation of more frequent checks, there remained missing documentation and continued inconsistencies in the administration and recording of tube feedings. The facility was unable to provide evidence that the resident consistently received the prescribed amount of nutrition, and staff were unable to explain discrepancies in the records.
Insufficient Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to provide sufficient dietary staff to ensure timely meal service for residents, as evidenced by interviews, observations, and record reviews. The Director of Food and Beverage (DFB) confirmed that the department was operating with 63 staff members instead of the required 75, and that efforts to recruit and orient new staff were ongoing. Due to staffing shortages, the third-floor satellite kitchenette was closed, and meals for that floor were being served from the second floor, further straining the available staff and impacting meal delivery times. Multiple residents reported and were observed experiencing significant delays in meal service. One resident stated that breakfast was an hour late and dinner was two hours late on a previous occasion. During a dining observation, several residents waited extended periods for their meal trays, with some expressing frustration and discomfort. Staff confirmed that kitchen staffing shortages led to delayed meal service, and that all meals for certain floors had to be prepared and delivered from other locations within the facility, resulting in some residents not receiving their meals until well after the scheduled times. Facility policies reviewed indicated that food and nutrition services are expected to provide adequate staffing to meet residents' dietary needs and ensure timely meal delivery. However, the observed and reported delays, as well as the closure of a satellite kitchen due to lack of staff, demonstrated that the facility was not meeting its own standards or the needs of its residents. The deficiency affected a large number of residents who rely on the facility for their daily nutrition and meal service.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to provide palatable food products at safe and appetizing temperatures for residents, as evidenced by observations and temperature recordings of meal trays. During lunch service, food trays were transported in a non-insulated cart, and upon arrival, the temperatures of several hot food items, including pork loin, fried item, snap peas, and egg roll, were found to be below the required 135°F as specified by the 2022 FDA Model Food Code. The beverage was served at 42.1°F, and the dessert was at room temperature. These findings were based on direct observation and temperature measurement of a resident's meal tray. Interviews with the Director of Food and Beverage confirmed the meal service times and the use of the non-insulated transport cart. Review of facility policies revealed that food and nutrition services staff are expected to ensure meals are palatable, attractive, and served at safe temperatures, with procedures in place for reporting and replacing meals that do not meet these standards. Despite these policies, the observed practices did not align with the stated guidelines, resulting in the provision of food that was not maintained at appropriate temperatures for 103 residents who consume food products.
Failure to Maintain Food Service Equipment and Properly Date Mark Perishables
Penalty
Summary
Surveyors observed that the facility failed to effectively clean and maintain food service equipment and did not properly date mark all potentially hazardous ready-to-eat food products. During a tour of the food service areas, two unopened half-gallon containers of milk with expired manufacturer's use-by dates were found in a satellite kitchenette refrigerator. Additionally, the ice dispensing spout of an ice machine was found with accumulated and encrusted mineral deposits, and a coffee machine was observed to have accumulated and encrusted food residue on its dispensing spouts, undersplash, backsplash, and drip tray assembly. The Director of Food and Beverage confirmed that the coffee machine was supposed to be cleaned daily. Record reviews of facility policies revealed that kitchenettes and equipment such as juice, cocoa, coffee makers, and ice machines were to be cleaned and sanitized regularly by staff, and that all perishable items were to be labeled with item name, employee initials, date and time of preparation, and use-by date. The policies also required that perishables be stored in a manner that maintains safety and freshness, and that date marking should follow a 'day of plus six' system. These practices were not consistently followed, as evidenced by the observations of expired milk and unclean equipment.
Improper Maintenance and Cleaning of Outdoor Waste Receptacle Area
Penalty
Summary
Surveyors observed that the facility failed to properly maintain two out of five outdoor waste receptacles, with one having a broken plastic lid and another having a broken plastic slider panel. Additionally, miscellaneous items such as a wooden pallet, vinyl gloves, and paper products were found resting on the concrete pad surface adjacent to the waste receptacles. The facility's policy requires that the dumpster area be free of debris on the ground and that lids remain closed, but these requirements were not met during the inspection. These deficiencies affected 105 residents.
Insufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple resident and staff interviews, as well as a review of staffing schedules. Several residents reported significant delays in receiving assistance, particularly with call light responses and help with activities of daily living such as toileting and mobility. One resident described waiting five to six minutes for bathroom assistance and an additional ten minutes after finishing, while another reported waiting up to an hour and a half for help after experiencing bowel incontinence. A third resident indicated that assistance was sometimes unavailable during the midnight shift, with call light response times ranging from immediate to as long as three hours, especially in the evenings. Staff interviews corroborated these accounts, with CNAs reporting that the second floor, housing approximately 34 residents, was often staffed with only one or two CNAs during certain shifts, particularly overnight. Staff noted that when nurses assisted with resident care, they were better able to meet resident needs, but agency nurses typically did not help CNAs. There were also instances where CNAs were required to assist with meal service due to dietary staff shortages, further reducing their ability to provide direct care. Staffing schedules confirmed that on multiple occasions, only one CNA was assigned to care for an entire floor during overnight shifts, and that ideal staffing levels were not consistently maintained. Additional staff interviews highlighted that inadequate staffing was a persistent issue, especially on weekends, with only two CNAs assigned to entire units. This resulted in critical care activities, such as turning and repositioning residents and performing daily hygiene routines, not being completed as required by residents' care plans. The combination of low staffing levels and additional non-nursing duties prevented staff from delivering care in accordance with established care plans, directly contributing to the deficiency.
Failure to Immediately Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to immediately report an allegation of resident-to-resident abuse to the Nursing Home Administrator as required. On the day of the incident, a cognitively intact resident was reportedly assaulted by another resident, as relayed by the first resident’s family member to an LPN. The LPN, who was assigned to both residents, observed one resident yelling and the other resident shutting the door, but did not witness any visible injuries or hear a direct allegation of abuse at that time. Despite receiving a phone call from the resident’s friend alleging an assault, the LPN did not notify the Nursing Home Administrator or Director of Nursing, believing that nothing significant had occurred since the resident appeared unharmed and did not verbalize abuse. A few hours later, police arrived at the facility after being contacted by the resident’s family, at which point the resident reported being struck in the head by the other resident. The Nursing Home Administrator was not made aware of the abuse allegation until the following day, when the Director of Nursing attended a care conference with the resident and their family. This delay in reporting resulted in the investigation not being initiated until the day after the alleged incident.
Failure to Timely Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) assessment in a timely manner for one resident. The clinical record review showed that a resident admitted with kidney failure and diabetes was transferred to the hospital on 3/15/24, but no discharge MDS assessment had been completed or transmitted as required. During interviews, it was revealed that the MDS nurse responsible for discharge MDS assessments and submissions was not present, and another MDS coordinator acknowledged that the discharge MDS should have been completed and transmitted within 14 days of discharge but was overlooked.
Inaccurate Discharge MDS Assessment Coding
Penalty
Summary
The facility failed to ensure the accuracy of a discharge Minimum Data Set (MDS) assessment for one resident. The clinical record showed that the resident was admitted to the facility and later found unresponsive, resulting in a transfer to the hospital where the resident subsequently died. However, review of the discharge MDS revealed that question A2105 was incorrectly coded to indicate the resident went home, rather than being transferred to an acute care hospital. During interviews, MDS coordinators confirmed that the resident was not discharged home and that the MDS should have been coded to reflect a hospital transfer.
Failure to Provide and Document Required Bathing Assistance
Penalty
Summary
A deficiency was identified when a resident, admitted with diagnoses including depression, seizure disorder, and fracture, and requiring one-person assistance for bathing, did not receive adequate support with activities of daily living (ADLs), specifically bathing. Observation revealed the resident's hair was greasy and unkempt, and the resident reported having received only one shower since admission, despite requiring assistance. The resident expressed dissatisfaction with her hygiene and stated that staff were aware her showers had not been completed. Review of the resident's clinical and task records showed no documentation of showers or baths provided since admission, with only 'not applicable' responses recorded. The DON confirmed that showers should be offered twice weekly and that refusals should be documented, with a bed bath provided if a shower is refused. However, no documentation was found to support that showers or alternative hygiene care were provided, and no additional records were produced to verify care delivery. Facility policy requires appropriate support and assistance with hygiene for residents unable to perform ADLs independently.
Failure to Administer Medication and Wound Care as Ordered
Penalty
Summary
The facility failed to ensure that wound treatments and medication administration were provided as ordered for two residents. One resident with Type 2 Diabetes Mellitus, diabetic neuropathy, major depressive disorder, and anxiety disorder did not receive her prescribed weekly diabetes medication, Mounjaro, on three out of six scheduled occasions. Documentation showed that the medication was unavailable on those dates, and there was no evidence that the facility physician was notified of the missed doses. Progress notes indicated that the nurse did not document contacting the pharmacy or physician, and the DON confirmed that staff are expected to reach out to both and document these actions when a medication is unavailable. Another resident with dementia, peritoneal abscess, cutaneous abscess of the abdominal wall, major depressive disorder, and bipolar disorder had a wound requiring dressing changes every eight hours. The treatment administration record showed that several scheduled dressing changes were not documented as completed, and there was no documentation explaining the missed treatments. The resident reported that dressing changes were sometimes missed, and the DON confirmed that there was no documentation of the rationale for the missed wound care. Both deficiencies were identified through observation, interview, and record review, revealing a lack of adherence to physician orders and facility policy regarding medication and wound care administration. The failures included missed doses and treatments, lack of documentation for missed care, and insufficient communication with the physician and pharmacy as required by facility policy.
Medications Left Unattended in Resident Room Without Proper Supervision
Penalty
Summary
A deficiency was identified when a resident, who had a history of hemiplegia and hemiparesis following a stroke and was cognitively intact, was observed with a medication cup containing six pills left unattended on a stand in their room. The observation occurred in the morning, and the pills were confirmed by the RN to be the resident's morning medications. The RN explained that the resident had a physician order stating that nursing staff should not stand over him while he took his medications, but could observe from a visual distance to ensure all medication was taken. Despite this order, the Director of Nursing confirmed that the resident did not have approval to self-administer medications, and facility policy required nurses to observe residents taking their medications unless self-administration was specifically authorized by a physician. The failure to ensure the medications were administered as required and not left unattended in the resident's room constituted a breach in safe medication storage and administration practices.
Infection Preventionist Lacked Required Training Documentation
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist had completed the required specialized training in infection prevention and control. The Infection Preventionist, a registered nurse, was unable to provide a certificate of completion for the necessary training and reported that she had only recently begun retaking the course, which was not yet finished. Additionally, the Director of Nursing confirmed that the facility could not locate any certificate of completion for the Infection Preventionist, and no other employee was overseeing the infection prevention and control program during this period.
Resident Sent to Appointment Without Proper Clothing, Dignity Not Maintained
Penalty
Summary
A resident with a history of traumatic subdural hemorrhage and muscle weakness, who was cognitively intact and required substantial to maximal assistance with lower body dressing, was sent to an outside medical appointment without proper clothing. The resident was transported wearing only a brief and covered with a sheet, without pants, a coat, or a hat, despite cold weather conditions. The resident and his family member reported that clean pants, a coat, and a hat were visibly available in the resident's room at the time, and the family member confirmed that multiple pairs of pants were present at the facility. The nurse responsible for sending the resident to the appointment stated she was unable to find clean or dry pants and felt rushed due to the transportation provider's arrival, leading her to wrap the resident in a blanket or sheet. The nurse did not see the available clothing items in the resident's room and did not reach out to the laundry department, which maintains emergency clothing for such situations. The resident expressed feeling cold and humiliated by the experience. Facility policy requires residents to be treated with dignity and respect, including proper attire and privacy during care.
Failure to Monitor Respiratory Status and Administer Medications
Penalty
Summary
The facility failed to adequately assess and monitor the respiratory status of a resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. The resident was dependent on supplemental oxygen, with orders to maintain blood oxygen saturation levels between 88% and 92%. However, there were multiple instances where the resident's oxygen saturation levels were recorded below the prescribed range, and there was no documented follow-up or adjustment to the oxygen therapy. Additionally, the resident's lung sounds were not consistently assessed before and after administering nebulizer treatments, as required by the physician's orders. Another resident with acute and chronic respiratory failure and asthma did not receive their prescribed Budesonide Inhalation Suspension as ordered. The medication was not administered on several occasions due to unavailability, and there was no documentation that the physician was notified of the missed doses. The facility's Director of Nursing indicated that the expectation was for the pharmacy to be contacted and for the physician to be informed if medications were not administered. Interviews with facility staff revealed a lack of awareness and adherence to the protocols for monitoring and administering respiratory treatments. A Licensed Practical Nurse admitted to not remaining with the resident during nebulizer treatments, despite knowing the resident sometimes removed their nebulizer mask. The Director of Nursing confirmed that lung sounds should have been assessed with each nebulizer treatment and that the physician should have been notified of any issues with medication availability.
Failure to Educate Non-Clinical Staff on Elopement Procedures
Penalty
Summary
The facility failed to educate non-clinical staff about the use of wander guards, alarmed exit doors, and staff responsibilities during an elopement, which resulted in a resident exiting the facility. The resident, who was assessed as an elopement risk and had a wander device placed on her wrist, managed to leave the building when the Admissions Director opened the door for visitors. The alarm was triggered, but the Admissions Director did not understand its significance and did not take action to bring the resident back inside. The resident, who had a history of wandering and attempts to exit the building, was outside for approximately one minute before being escorted back inside by staff. The resident was alert, dressed appropriately, and had a BIMS score of 8, indicating she was able to be interviewed. Despite the alarm sounding, the Admissions Director, who was not familiar with long-term care, did not recognize the need to respond to the alarm. Interviews with various staff members revealed a lack of education and documentation regarding the facility's elopement procedures and the use of wander guards. The Director of Maintenance and Grounds and the Infection Control/Staff Development RN both indicated that non-clinical staff were not adequately oriented on these procedures. The facility's policies on resident wandering and elopement were not effectively communicated to new employees, contributing to the incident.
Failure to Follow Care Plans Leads to Resident Falls
Penalty
Summary
The facility failed to prevent accidents by not adhering to the care plans for two residents, resulting in actual harm for one resident and potential harm for another. Resident #3, who had a history of falls and multiple medical conditions, including COPD, diabetes, and epilepsy, suffered a fall that resulted in fractures of the right tibia and fibula. The fall occurred during a transfer from the toilet to a wheelchair, where the resident was assisted by only one CNA, contrary to the care plan that required a two-person assist. The CNA involved was not aware of the care plan requirements and had not been educated on the necessity of reading the Kardex prior to providing care. Resident #2, who had diagnoses including Alzheimer's disease, dementia, and a below-knee amputation, experienced a fall in the bathroom when a CNA attempted to assist him without using the required mechanical lift, the EZ-Stand. The resident was unable to stand, and another CNA had to assist in lowering him to the floor. The CNA assisting the resident was new and unaware of the requirement to use the EZ-Stand, as she did not read the Kardex and relied on verbal information from other CNAs. The personnel records revealed that the CNA involved in both incidents had not completed a competency evaluation upon completion of her orientation. The lack of adherence to the care plans and the failure to ensure that staff were adequately trained and informed about resident care requirements led to these incidents, highlighting deficiencies in the facility's supervision and training processes.
Failure to Report Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to report allegations of abuse or neglect concerning a resident who sustained injuries due to improper care. The resident, who was admitted with multiple medical conditions including COPD, diabetes, and a history of falls, experienced a fall at the facility that resulted in fractures to her right leg. The resident was supposed to be transferred with the assistance of two staff members, as per her care plan, but was instead assisted by only one Certified Nurse Aide (CNA), leading to the fall and subsequent injuries. The incident occurred when the resident was being transferred from the toilet to her wheelchair. The CNA involved in the transfer was not aware of the requirement for two-person assistance and admitted to not reading the Kardex, which outlines the care plan for residents. The CNA had only been employed at the facility for a month and had not completed a competency evaluation after her orientation. This lack of adherence to the care plan and insufficient training contributed to the resident's fall and injuries. The Nursing Home Administrator was aware of the incident but did not ensure that it was reported as a potential case of neglect to the appropriate State Agency. The administrator acknowledged that the failure to follow the care plan could be considered neglect but did not take immediate action to report it. This oversight in reporting and investigating the incident promptly represents a deficiency in the facility's handling of potential abuse or neglect cases.
Failure to Follow Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to investigate, implement preventive measures, and take corrective action for an allegation of neglect involving a resident. The resident, who was admitted with multiple diagnoses including COPD, diabetes, and a history of falls, experienced a fall at the facility that resulted in fractures to her right leg. The resident was being transferred from the toilet to her wheelchair by a single CNA, despite her care plan requiring a two-person assist for transfers. This failure to follow the care plan led to the resident's fall and subsequent injuries. The incident occurred when the resident's right leg gave out during the transfer, causing her to fall to the floor. The CNA involved in the transfer was not aware of the resident's need for a two-person assist and admitted to not reading the Kardex, relying instead on verbal information from other CNAs. The CNA had been employed at the facility for a month and had not completed a competency evaluation upon finishing her orientation. The Nursing Home Administrator was aware of the incident but was on vacation at the time. Upon returning, the Administrator acknowledged that the failure to follow the care plan could be considered neglect. However, the incident was not immediately investigated or reported to the appropriate state agency, as required. The lack of immediate investigation and reporting highlights a deficiency in the facility's response to the incident.
Failure to Complete CNA Competency Evaluations
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs) had completed the required initial competency evaluations necessary to care for residents. The personnel records for CNAs D, E, F, G, and H did not demonstrate completed competency evaluations upon the completion of their orientation. CNA D was hired on June 17, 2024, CNA E on August 24, 2023, CNA F was a contracted CNA starting on December 28, 2023, CNA G was hired on May 30, 2024, and CNA H on May 16, 2024. Despite these CNAs working independently, their competency evaluations were not documented as completed. During interviews, the Human Resource Director and Nurse Educator confirmed the absence of the completed competency evaluation forms for these CNAs. The Human Resource Director was unable to locate the forms, and the Nurse Educator explained that competency evaluations were supposed to be completed by Nurse Managers after orientation, allowing staff to work independently. However, the Nurse Educator could not explain why the evaluations were not completed, indicating a lapse in the facility's process for ensuring staff competency.
Failure to Prevent Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of pressure ulcers for three residents, resulting in multiple facility-acquired pressure ulcers. Resident #13 developed pressure ulcers on both heels due to prolonged pressure from resting on the bed. Despite being at risk for pressure ulcer development, no preventive measures such as offloading devices were initially used. After the ulcers were discovered, interventions like foam boots and a foam wedge were implemented, but the ulcers had already progressed to stage two and three. The resident's resistance to using offloading devices was noted, but there were no documented refusals of care in the medical record. Resident #24 developed a pressure ulcer on the lateral side of the left foot due to a medical device (external fixator) pressing into the skin. The resident's care plan and Kardex did not include instructions to elevate the left lower extremity as per orthopedic instructions. Multiple CNAs confirmed that they did not see a foam cushion used to elevate the resident's leg. The wound nurse and other staff were unaware of how the pressure injury developed, indicating a lack of communication and adherence to preventive measures. Resident #45 developed a deep tissue injury on the left heel and a stage two pressure ulcer on the coccyx. The resident's care plan included an order to keep the left lower extremity elevated, but observations revealed that the heel was resting directly on the mattress. The wound nurse attributed the development of the pressure ulcers to the use of flat pillows and irregular staffing, as the resident's regular CNA was on vacation. The lack of consistent care and proper offloading techniques contributed to the resident's pressure ulcers.
Failure to Prevent Recurrent Falls and Provide Adequate Supervision
Penalty
Summary
The facility failed to implement timely interventions, provide appropriate supervision, and ensure that staff assisted with transfers to prevent recurrent falls for two residents. Resident #70, a male with a history of Parkinson's Disease, polyosteoarthritis, and multiple fractures, experienced a fall three days after admission. He was found on the floor with a head laceration after calling his wife for help. The staff was alerted by the wife, and there was a delay in attending to the resident. The resident required emergency care and staples for the head injury. The fall incident report lacked details on when the resident was last observed or if any interventions were in place at the time of the fall. The facility's design and staffing issues were noted as contributing factors to the delay in assistance and supervision. Resident #547, a female with a history of hypotension, falls, and a subdural hematoma, experienced two falls within a short period after admission. The first fall resulted in a head laceration requiring staples, and the second fall occurred three days later, causing another head laceration. Both falls were unwitnessed, and the incident reports did not provide information on when the resident was last observed or if the call light was used. The care plan did not include new interventions after the first fall, and there was a lack of follow-up documentation. The facility's layout and staffing issues were again noted as contributing factors to the lack of supervision and timely assistance. Interviews with staff revealed that the facility had identified a need for improvement in root cause analysis and gathering additional information at the time of falls. The Director of Nursing and Registered Nurse responsible for fall investigations acknowledged the deficiencies in the fall reports and the lack of new interventions in the care plans. The facility's design and staffing challenges were highlighted as ongoing issues affecting the supervision and safety of residents, particularly those at high risk for falls.
Failure to Maintain Clean and Functional Food Service Equipment
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, impacting 88 residents. During an initial tour of the food service area, the TurboChef oven was found with accumulated and encrusted food residue. The Director of Food and Beverage acknowledged the issue and indicated that staff would clean and sanitize the oven. Additionally, the vegetable preparation sink faucet was leaking, and the overhead spray arm spring near the mechanical dish machine was weak, allowing the valve assembly to invade the flood plane level of the sink basin. These conditions were in violation of the 2017 FDA Model Food Code sections 4-601.11 and 5-205.15, which require food-contact surfaces to be clean and plumbing systems to be maintained in good repair, respectively. Further inspection of the Center for Health & Rehabilitation (CHR) 2 Kitchenette revealed that the interior surface of the juice machine was also soiled with accumulated and encrusted food residue. The Director of Food and Beverage again indicated that staff would clean and sanitize the machine. Record reviews of the facility's policies and procedures showed that maintenance service was supposed to be provided to all areas of the building, grounds, and equipment, and that kitchenettes were to be cleaned regularly by Nursing and Hospitality Services staff. However, these policies were not effectively implemented, leading to the observed deficiencies.
Failure to Maintain Clean and Safe Physical Plant
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, affecting 88 residents. During an environmental tour of the facility's laundry service, the chemical room's entrance door was found with a damaged laminate surface, and the exhaust ventilation grill was soiled with accumulated dust and dirt. In a common area tour, multiple issues were noted, including soiled ventilation grills in the shower room, a loose commode base seat and stained ceiling in the public restroom, and a soiled utility room refrigerator with accumulated ice. Additionally, the mop closet had a non-functional light bulb and a soiled ventilation grill, while the therapy restroom also had a soiled ventilation grill. On the third floor, the mop closet had a cracked sink basin and damaged plaster wall, and the public restroom had a soiled ventilation grill. Further observations in sampled resident rooms revealed soiled ventilation grills, damaged drywall surfaces, and loose or missing vinyl base coving in several restrooms. The facility's maintenance work order system, WorxHub, did not have specific entries related to these maintenance concerns. A review of the facility's maintenance policy indicated that the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. However, the observed deficiencies indicate a failure to adhere to this policy, leading to an increased likelihood of cross-contamination, bacterial harborage, and decreased air quality.
Failure to Change PICC Line Dressing Timely
Penalty
Summary
The facility failed to provide services that met acceptable standards of clinical practice for PICC line dressings for Resident #543. The resident, a [AGE] year old male with a recent right great toe amputation and current IV antibiotic treatment, had a PICC line with a dressing dated 5/20/24. Observations on 5/21/24 and 5/23/24 revealed that the dressing, which included gauze under a transparent covering, had not been changed within the required 48-hour period. The resident's right arm was visibly swollen compared to the left arm, and there was a blood stain on the dressing. Despite these signs, there were no nursing progress notes mentioning the swelling from 5/20/24 to 5/23/24, and the physician was not aware of the issue until it was reported on 5/23/24. Interviews with staff, including the LPN, Unit Manager, and DON, confirmed that the dressing should have been changed within 48 hours to assess the insertion site for signs of infection. The LPN reported being unable to see the insertion site due to the gauze covering, and the DON stated that staff are expected to report abnormal findings to the physician and document them in the medical record. The failure to change the dressing and assess the site as required increased the likelihood of infection for the resident.
Failure to Ensure Adequate Food and Fluid Intake
Penalty
Summary
The facility failed to ensure that Resident #24 received an assessment for meal consumption assistance and sufficient food intake, resulting in significant weight loss. Resident #24, who was admitted with multiple diagnoses including cognitive communication deficit and muscle weakness, was observed multiple times with untouched meals and nutritional supplements. Despite being noted as independent for eating in the care plan, Resident #24 was often found sleeping during meal times and did not stay alert long enough to consume food. The resident's weight dropped from 207.8 lbs on 2/22/2024 to 165.1 lbs on 5/21/2024, indicating a 20.55% weight loss. Observations revealed that the resident's meals and nutritional supplements were often left unattended and untouched, and the resident was not adequately monitored or assisted during meal times. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), confirmed that Resident #24 was not consuming meals due to decreased alertness and cognition. The Registered Dietician (RD) also noted difficulty in monitoring the resident's intake due to these issues. Despite initial assessments and recommendations for nutritional supplements, the resident's condition deteriorated, and subsequent assessments were not effectively carried out. The facility's failure to provide adequate assistance and monitoring for meal consumption led to the resident's significant weight loss and potential health risks.
Insufficient Nursing Staff Leads to Repeat Falls and Injuries
Penalty
Summary
The facility failed to ensure sufficient levels of nursing staff to meet resident needs and supervision, resulting in repeat falls including injury for two residents. Resident #70, a male with Parkinson's Disease and other conditions, experienced a fall three days after admission, resulting in a head laceration that required several staples. The resident's family reported difficulty in reaching the facility by phone, leading to a delay in assistance. The fall was unwitnessed, and the investigation lacked details on when the resident was last observed or if interventions were in place. The facility's design and staffing levels were cited as contributing factors to the incident. Resident #547, a female with a history of falls and other medical conditions, experienced two falls within a short period after admission. The first fall resulted in a head laceration requiring staples, and the second fall occurred three days later, causing another head laceration. Both falls were either unwitnessed or witnessed but not prevented, and the investigation reports lacked details on the last observation, call light usage, and specific interventions. The facility's layout and staffing levels were again noted as contributing factors. Interviews with staff, including LPNs and the Director of Nursing, revealed gaps in the fall investigation process and documentation. The facility's assessment indicated a high number of residents requiring assistance with daily activities, but the staffing levels were insufficient to meet these needs. The facility's design also made it difficult for staff to monitor residents effectively, particularly those at high risk for falls. The lack of timely and thorough investigations and appropriate interventions contributed to the repeated falls and injuries experienced by the residents.
Failure to Document and Address Pharmacist's Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician documented in the medical record that identified medication review irregularities were reviewed, the action taken, and/or the rationale for no changes to the medications for one resident. Resident #30, who was admitted with diagnoses including Alzheimer's Disease, schizophrenia, and major depressive disorder, had several recommendations from the pharmacist that were not addressed or documented properly. These recommendations included decreasing the dose of pantoprazole and obtaining a fasting lipid panel due to the potential of antipsychotic medications to cause hyperlipidemia. The recommendations from 8/27/23 and 3/18/24 were not addressed, and the physician's response to the recommendation on 12/31/23 was not documented in the medical record. Additionally, the order for laboratory tests recommended on 5/16/24 was written on 5/24/24, indicating a delay in action. The Director of Nursing (DON) confirmed that the recommendations from 8/27/23 and 3/18/24 were not addressed and that the physician's follow-up to the recommendation on 12/31/23 was not documented in the medical record. The DON also reported that the order for laboratory tests recommended on 5/16/24 was written on 5/24/24. This lack of documentation and follow-up on the pharmacist's recommendations indicates a failure in the facility's process to ensure proper medication management and review for Resident #30.
Failure to Monitor Antipsychotic Medication
Penalty
Summary
The facility failed to ensure adequate monitoring with the use of an antipsychotic medication for one resident. The resident was admitted with diagnoses including Alzheimer's Disease, schizophrenia, and major depressive disorder. The resident was prescribed risperidone for schizophrenia, with a physician's order to check lipid panel every 6 months. Despite recommendations from the pharmacist on two occasions to obtain a fasting lipid panel, the last lipid panel was conducted over a year ago. The Director of Nursing confirmed that the most recent lipid panel was completed in February 2023.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, resulting in an 8% error rate. This was observed when an LPN administered bisacodyl to a resident without a corresponding physician's order and failed to administer a prescribed probiotic and loperamide. The resident, who was cognitively intact, had a physician's order for a probiotic daily and loperamide for loose stools. The LPN reported that the medications were not in stock, although they documented the probiotic as administered. The resident experienced loose stool/diarrhea later that day. The Director of Nursing confirmed that probiotics were kept as a stock medication in the facility.
Failure to Administer Pneumococcal Immunizations
Penalty
Summary
The facility failed to offer pneumococcal immunizations per CDC recommendations for two residents. Resident #24, who has diagnoses including diabetes and chronic kidney disease stage 3, was admitted and readmitted to the facility. The resident's medical record showed they received Pneumovax 23 in 2015 and refused Prevnar 13. Despite consent being given for a pneumococcal immunization in November 2022, the resident did not receive the recommended dose of PCV15 or PCV20 at least one year after their last dose of PPSV23, as per CDC guidelines. Similarly, Resident #69, who has diagnoses including Parkinson's Disease, hypertension, and obstructive sleep apnea, was admitted to the facility. The resident's medical record indicated they received Pneumovax 23 in 2011 and 2015. Although consent for a pneumococcal immunization was given in November 2022, the resident did not receive the recommended dose of PCV15 or PCV20 at least one year after their last dose of PPSV23, as per CDC guidelines. The Infection Preventionist confirmed that both residents were due for and had consented to the pneumococcal immunization but did not receive it.
Failure to Offer Updated COVID-19 Vaccine
Penalty
Summary
The facility failed to offer an updated COVID-19 vaccine to one resident (R69) of five reviewed. Resident #69 was admitted with diagnoses including Parkinson's Disease, hypertension, and obstructive sleep apnea. The resident was cognitively intact, scoring 14 out of 15 on the BIMS. The medical record showed that the last COVID-19 vaccine was received on 1/16/23, and there was no documentation indicating that the resident was offered the updated 2023-2024 COVID-19 vaccine. During an interview, the Infection Preventionist confirmed that the resident was due for another COVID-19 vaccine and admitted that there was no record of consent or declination from the resident.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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