Faith Haven Senior Care Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Michigan.
- Location
- 6531 W Michigan Avenue, Jackson, Michigan 49201
- CMS Provider Number
- 235359
- Inspections on file
- 24
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Faith Haven Senior Care Centre during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, unable to reliably communicate, was being transferred to bed with a mechanical lift when a CNA struck or tapped the resident on the head while the resident was agitated and mumbling. An LPN present reported that the CNA then moved close to the resident’s face, taunted the resident, grabbed the resident’s hands, and pushed them down after the resident raised her hands and stated she would report him, with the CNA allegedly laughing and saying nobody cared about her. The CNA admitted to hitting the resident on the head to gain attention and acknowledged the resident’s threat to report him, while denying verbal abuse. The facility’s abuse policy defines such hitting as physical abuse and disparaging language as verbal abuse, yet the administrator provided no explanation for the head strike, denied awareness of verbal abuse allegations, and there was no past non-compliance document related to this incident in the facility’s records.
A resident with dementia and severe cognitive impairment was allegedly tapped on the head, yelled at, taunted, and had her hands pushed down by a CNA after she became agitated during care, with the CNA reportedly laughing and saying that nobody cared about her when she stated she would report him. An LPN witness later described these events in detail to surveyors, but the facility’s incident file contained only an incomplete, unsigned word-processed statement lacking key details, dates, and interviewer information, while the CNA’s statement was on a formal facility form and minimized the interaction to a light tap and a request for the resident to stop saying she would report him. The administrator denied knowledge of verbal abuse allegations, could not reconcile conflicting accounts or documentation formats, and the facility failed to follow its abuse policy requiring comprehensive, signed, and dated interviews and written statements for all involved, resulting in no thorough investigation of the alleged verbal abuse or the CNA’s conduct.
The facility did not ensure that residents were protected from all forms of abuse and neglect, resulting in a deficiency related to resident safety and well-being.
A deficiency was cited when a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights was not upheld by the facility.
A resident with complex medical and psychiatric needs submitted written grievances alleging that an RN threatened her life, failed to process a physician's order for pain medication, and treated her unequally. Despite these allegations being recognized as abuse, the facility did not report the incident to authorities within the required timeframe, instead delaying the report by 20 days.
A resident with a recent shoulder replacement and multiple sclerosis did not receive necessary restorative services due to a breakdown in communication and documentation within the facility. Despite recommendations for restorative therapy, the resident's care plan lacked orders for such services, resulting in a deficiency. The facility is auditing past referrals for compliance.
The facility failed to provide coffee at a palatable temperature, as reported by residents and observed during interviews. Residents noted that coffee was poured and left on the counter for extended periods, leading to it being served cold. Despite repeated complaints documented in Resident Council meetings, no effective solution was implemented. A resident, who was the Resident Council President, confirmed the issue, and the Dietary Manager acknowledged the problem but did not measure coffee temperatures upon delivery. The facility lacked a hot liquid policy, and no documentation was provided to show efforts to resolve the issue.
A resident with multiple health conditions experienced frustration and embarrassment due to the facility's failure to respond to her call light in a timely manner. Despite the call light being on for over 30 minutes, staff did not respond promptly, leading to the resident having accidents. The facility uses a pager system for call lights, but the assigned CNA did not have a pager on during the incident. Previous complaints about slow response times were noted in Resident Council Meeting minutes and Grievance Logs.
The facility failed to address grievances from residents participating in Resident Council meetings, including concerns about cold coffee temperatures and requests for a different cable package and a television in the dining room. Despite repeated documentation of these issues over several months, there was no evidence of resolution or communication back to the residents, and the facility did not meet its policy requirements for responding to concerns.
The facility failed to ensure accurate MDS assessments for three residents, leading to incorrect diagnoses and discharge documentation. One resident was inaccurately coded with schizophrenia instead of bipolar disorder, another had an incorrect diagnosis of schizoaffective disorder bipolar type, and a third resident's discharge was incorrectly documented as a facility death instead of a hospital death.
A resident with a recent shoulder replacement did not receive necessary restorative therapy due to a lapse in communication and documentation between therapy and nursing departments. Despite a recommendation for therapy, the resident's care plan was not updated, resulting in unmet care needs and continued pain.
A resident developed moisture-associated skin damage (MASD) and incontinence-associated damage (IAD) to the sacrum area while in the facility. Despite a wound evaluation recommending specific interventions, the care plan was not updated to include these changes. The care plan had not been revised since October, and an observation revealed open skin areas. The wound nurse indicated that the unit manager was responsible for revising care plans, but this was not done.
The facility failed to ensure accurate diagnostic practices for two residents, leading to incorrect diagnoses in their medical records. One resident was inaccurately documented with schizophrenia instead of bipolar disorder, while another had an incorrect diagnosis of schizoaffective disorder bipolar type. Interviews revealed a lack of verification and errors in the computerized system, contributing to these inaccuracies.
A resident in a LTC facility, who required assistance with daily living activities, did not receive adequate oral hygiene care. Despite being cognitively intact and cooperative, the resident was observed with caked debris on their teeth and severe halitosis. The care plan indicated oral hygiene should be performed every shift, but the resident reported not receiving necessary supplies or assistance, and staff interviews confirmed a lack of time to provide care.
The facility failed to follow a physician's order for a resident with multiple sclerosis, delaying the administration of Trazodone for insomnia. Additionally, another resident with severe cognitive impairment was improperly positioned in a wheelchair, with feet dangling and not reaching the footrests. Communication breakdowns and lack of timely action contributed to these deficiencies.
The facility failed to ensure physician follow-up on pharmacy recommendations for two residents. One resident was on multiple pain medications without clarification on their use for different pain levels, and another had unaddressed recommendations regarding medication diagnosis and timing. The oversight was noted by the DON and RCD, with hospitalization cited as a factor.
The facility failed to adhere to medication administration parameters for a resident with hypertension, administering Lisinopril despite low blood pressure readings. Additionally, another resident with a UTI was given an inappropriate antibiotic, Bactrim DS, despite culture results indicating resistance. The delay in changing the antibiotic was due to staff absence over the holiday, and the facility did not follow expected infection screening protocols.
A facility failed to attempt a gradual dose reduction (GDR) for a resident prescribed Prozac 40 mg for depression and bipolar disorder. Despite a plan to attempt a GDR, no reduction was ordered or attempted, and the resident's medication remained unchanged. Additionally, the resident had not been seen by behavioral health services since the GDR was supposed to be considered, and the social worker confirmed the oversight and lack of monthly follow-up.
A resident with severe cognitive impairment and multiple health conditions did not receive timely dental services for broken and lost dentures. Despite being on the list for dental visits, the resident's dentures were not repaired or replaced due to inadequate communication and coordination between the facility and dental service providers.
A facility failed to provide sanitary incontinence care for a resident with severe cognitive impairment. A CNA was observed using a cloth with feces, rinsing it in the toilet and sink, and then using it to clean the resident. The CNA admitted to the unsanitary practice, believing toilet water was the same as sink water, and was on suspension at the time of the interview.
Failure to Protect a Cognitively Impaired Resident From Physical and Verbal Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and verbal abuse by a CNA. The resident had dementia with severe cognitive impairment, as evidenced by a BIMS score of 3/15, and was not reliably interviewable. On the date of the incident, the resident was in her room, agitated and mumbling, when a new LPN entered to assist a CNA with transferring the resident to bed using a mechanical lift. According to the LPN’s account, the CNA tapped or hit the resident on the head while the resident was mumbling, and the resident reacted by saying she would report him. The LPN reported that after the head strike, the CNA retrieved the resident’s communication whiteboard and wrote that the LPN was there to help, but the resident remained agitated and raised her hands. The LPN stated that the CNA then got in the resident’s face, taunted her, grabbed her hands, and pushed them down. The resident reportedly told the CNA she would report him to the state, and the CNA allegedly laughed and responded that nobody cared about her. The LPN described feeling very uncomfortable with the CNA’s aggressive treatment and remained with the resident afterward because the resident was upset, afraid, and stated she did not like being hit on the head. In his written and verbal statements, the CNA admitted to hitting or tapping the resident on the head to get her attention, acknowledging he could have chosen to tap her shoulder or arm instead. He confirmed that the resident said she would report him, though he denied verbally responding to that statement. The facility’s abuse policy defines physical abuse as including hitting and slapping, and verbal abuse as the use of disparaging or derogatory language toward residents. The administrator acknowledged the CNA’s physical contact with the resident’s head but offered no explanation for it and stated he was not aware of any verbal abuse allegation. There was no past non-compliance document related to this incident in the facility’s records, despite the reported physical and verbal interactions described by the LPN and partially acknowledged by the CNA.
Failure to Thoroughly Investigate Allegations of Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate allegations of abuse involving one resident with severe cognitive impairment and dementia. The resident was non-interviewable per a recent MDS, and was observed to be pleasantly confused. An incident file contained an unsigned word-processed statement attributed to an LPN describing an event in which a CNA tapped the resident on the head, yelled “Stop,” taunted the resident, pushed the resident’s hands down, laughed, and told the resident that nobody cared about her after she said she would report him. This document lacked basic investigative elements such as the date of the incident versus the interview date, the identity of the interviewer, and whether the interview was conducted in person or by phone. The statement also did not capture the full extent of the alleged verbal abuse and physical interaction later described by the LPN in a surveyor interview. In a subsequent phone interview with the surveyor, the LPN provided a more detailed account, stating she was a new employee and that upon entering the resident’s room she saw the CNA hit the resident on the head, yell “Stop,” retrieve the resident’s communication whiteboard, get in the resident’s face, taunt her, grab her hands, and push them down. The LPN reported that the resident said she would report the CNA to the state, and that the CNA laughed and said, “go ahead, nobody care about you.” The LPN stated she was very uncomfortable with the CNA’s aggressive treatment, remained with the resident because the resident was afraid and upset about being hit, and then reported the incident to another nurse, who told her the administrator had to be notified. The LPN stated she relayed the same chain of events to the administrator that she later described to the surveyor, but this level of detail and the alleged verbal abuse were not reflected in the facility’s written incident documentation. The CNA’s written statement, in contrast, was on a facility form that included the name and position of the person interviewed, the interviewer, the date of the interview, the date of the incident, and the location. In that statement, the CNA acknowledged tapping the resident on the head to get her attention and admitted he could have chosen to tap her shoulder or arm instead. He acknowledged the resident said she would report him and that he told her to stop saying that, but he did not document any verbal abuse. In a phone interview with the surveyor, the CNA again admitted hitting the resident on the head, denied responding when she said she would report him, and stated he learned of allegations of physical and verbal abuse from the administrator after being suspended. The administrator, however, denied awareness of any verbal abuse allegation, could not explain discrepancies between the LPN’s and CNA’s documentation, and offered no explanation for why the LPN’s interview was on an unsigned word document while the CNA’s was on a completed facility form. The facility’s abuse policy required comprehensive interviews of the resident, accused, and witnesses, with written, signed, and dated statements, but there was no documentation showing a complete investigation into the alleged verbal abuse, the CNA’s tone or intent, or whether his “go ahead” comment was abusive or encouraging of the resident’s rights, and no past non-compliance document was created for this incident.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect each resident from all types of abuse, including physical, mental, and sexual abuse, physical punishment, and neglect by any individual. The report identifies a deficiency related to the facility's inability to ensure residents were safeguarded from abuse and neglect, as required by regulations. Specific actions or inactions leading to this deficiency are not detailed in the report, nor are particular events or resident conditions described.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or observations involving individual residents.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to implement its policies and procedures for timely reporting of a reasonable suspicion of a crime, as required by section 1150B of the Act. A resident with multiple medical and psychiatric diagnoses, who was cognitively intact, submitted written grievances alleging that a registered nurse threatened her life and well-being, refused to listen to her wishes, and failed to process a physician's order to increase her pain medication. The resident referenced an EMS report related to a hospital transfer and expressed ongoing concerns about the nurse's conduct, including allegations of unequal treatment and threats. The nurse had previously received disciplinary action for not following through with physician orders, and documentation showed a pattern of similar issues. Despite the resident's written allegations, which were recognized by the covering Nursing Home Administrator as abuse allegations, the facility did not report the incident to the State Agency within the required two-hour timeframe. Instead, the formal report was made 20 days after the initial grievances were submitted. The delay in reporting was confirmed through interviews and record review, indicating a failure to follow mandated reporting procedures for suspected abuse or neglect.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide restorative services for a resident, resulting in a deficiency. The resident, a cognitively intact female with a history of multiple sclerosis and recent right shoulder replacement, was admitted to the facility with a need for assistance in transfers, ambulation, and toileting. Despite having received therapy services upon admission, these services were discontinued due to insurance issues. The resident reported significant pain and limited range of motion in her right shoulder, yet there was no evidence in her medical records or care plans of her recent shoulder replacement or any restorative therapy being provided. Interviews with facility staff revealed a breakdown in communication and process regarding the implementation of restorative therapy. The Therapy Director confirmed that a recommendation for restorative therapy was made upon the resident's discharge from therapy services, but the Director of Nursing was unaware of the responsibility to add these orders to the resident's care plan. The restorative referral form was not properly communicated or documented, leading to the resident not receiving the necessary restorative therapy between the specified dates. The facility was in the process of auditing past referrals for compliance following the surveyor's investigation.
Facility Fails to Serve Coffee at Palatable Temperature
Penalty
Summary
The facility failed to provide hot liquids at a palatable temperature, specifically coffee, to residents, as observed during a group interview and individual resident interviews. Four out of five residents in a group interview reported that the coffee was consistently served cold, a complaint that had been ongoing. The residents observed that coffee was poured into cups and left on the counter for about 30 minutes before being placed on trays, which contributed to the coffee cooling down. The Resident Council meeting minutes from previous months also reflected repeated complaints about the coffee temperature, but no effective solution had been implemented. Resident 61, who was cognitively intact and the Resident Council President, expressed dissatisfaction with the coffee temperature, stating that it was cold by the time it reached their room. Despite having a lid on their coffee cup, the temperature issue persisted. The resident's meal ticket specified that coffee should be served fresh from the machine, but this was not being adhered to. The Dietary Manager acknowledged receiving complaints about cold coffee and described the process of pouring coffee when tray tickets were printed, but the coffee was not served immediately, leading to temperature loss. The facility did not have a policy for hot liquids, and the Dietary Manager admitted that they did not measure the coffee temperature when it reached the residents. During a meal service observation, a Culinary Specialist instructed staff not to pre-pour coffee but to serve it directly from the machine to maintain temperature. Despite these observations and interviews, no documentation was provided to show efforts to address the issue, and the problem remained unresolved by the exit date.
Delayed Call Light Response Leads to Resident Frustration
Penalty
Summary
The facility failed to respond to a resident's call light in a timely manner, resulting in frustration and embarrassment for the resident. The resident, a cognitively intact female with a history of urinary tract infection, multiple sclerosis, and anxiety disorder, required assistance with transfers, ambulation, and toileting. On the day of the observation, the resident had her call light on for over 30 minutes, urgently needing to use the bathroom. Despite the call light being illuminated, no staff responded promptly, leading to the resident expressing that this delay in response happens frequently, causing her to have accidents. The facility uses a pager system for call lights, but on the day of the incident, the assigned Certified Nurse Aid (CNA) did not have a pager on, claiming to have started the shift without it. The call light monitoring system confirmed the call light was on for at least 16 minutes before being addressed. The facility's Clinical Care Coordinator and Nursing Home Administrator were unaware of the staff not wearing pagers and reported occasional complaints about slow response times. The resident's care plan indicated the need for one-person assistance, and previous Resident Council Meeting minutes and Grievance Logs reflected ongoing concerns about call light response times.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances from residents participating in the Resident Council (RC) meetings were promptly resolved and responded to in a timely manner. During a confidential group meeting, RC members expressed frustration that management discussed fixing problems but did not document or communicate updates on issues. Specifically, residents repeatedly raised concerns about cold coffee temperatures and requested a different cable package that included the ABC network, as well as a television in the main dining room. Despite these issues being documented in RC meeting minutes over several months, there was no evidence of resolution or communication back to the residents. The Nursing Home Administrator (NHA) A attended a December meeting and suggested taking test trays to check coffee temperatures, which added to residents' frustration as they had consistently reported the coffee was cold. The NHA A was unable to provide documentation of follow-up actions or responses to these grievances, and there were no assistance/concern forms related to the issues. The facility's policy required responses to concerns within 15 days and a written response within 30 days, but these timeframes were not met. The lack of documented responses and follow-up actions contributed to the deficiency in addressing resident grievances.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their medical records. Resident #66 was admitted with a diagnosis of bipolar disorder, but the MDS assessments inaccurately included a diagnosis of schizophrenia. Interviews with the Social Work Director, Unit Manager, and Regional Clinical Director revealed confusion and acknowledgment of the inaccuracy, as the schizophrenia diagnosis was not supported by the resident's medical history. Resident #64's medical record showed a diagnosis of schizoaffective disorder bipolar type, which was incorrect. The resident's MDS inaccurately documented schizophrenia, despite the resident having a history of bipolar disorder. The Social Worker and Nursing Home Administrator were unable to explain the source of the incorrect diagnosis, and the Regional Clinical Director noted that the computerized system may have automatically listed the wrong diagnosis, which should have been manually corrected. Resident #89's MDS inaccurately documented the type of discharge as a death in the facility, although the resident had died in the emergency department after being transferred for a routine visit. The Regional Clinical Director clarified that the MDS should have been coded as a discharge-return anticipated, as the resident was not admitted to the hospital. This error was identified through a review of the Resident Assessment Instrument manual and hospital records.
Failure to Implement Restorative Therapy for Resident Post-Surgery
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-centered care plan for a resident who had undergone a right total shoulder replacement. The resident, a cognitively intact female with multiple diagnoses including multiple sclerosis and anxiety disorder, was admitted to the facility and initially received therapy services. However, these services were discontinued due to insurance issues. Despite a recommendation for restorative therapy made by the therapy department upon discharge from therapy services, the resident did not receive the necessary restorative therapy for over a month. This resulted in unmet care needs, including limited range of motion and significant pain. The deficiency was further compounded by a lack of communication and documentation. The therapy department completed a restorative therapy referral, which was not properly communicated to the nursing department, as evidenced by the blank nursing signature line on the referral form. The Director of Nursing, who had been in the position for over six months, was unaware of the referral until the surveyor investigation. The resident's care plans and electronic medical records did not reflect the need for restorative therapy or the recent shoulder replacement, indicating a failure in updating and implementing the care plan to meet the resident's needs.
Failure to Revise Care Plan for Skin Breakdown
Penalty
Summary
The facility failed to revise the care plan for one resident, who was admitted with a risk for skin breakdown due to incontinence. The resident developed moisture-associated skin damage (MASD) and incontinence-associated damage (IAD) to the sacrum area while in the facility. Despite a wound evaluation identifying these issues and recommending interventions such as a heel suspension/protection device, a mattress with a pump, a positioning wedge, and a turning/repositioning program, the care plan was not updated to reflect these changes. The care plan had not been revised since October 9, 2024, and did not include the new interventions for the MASD/IAD issue. An observation on January 3, 2025, revealed three open skin areas on the resident. The wound nurse stated that the unit manager was responsible for revising care plans when new skin breakdowns were identified, but this had not occurred in this case.
Inaccurate Diagnostic Practices in Resident Records
Penalty
Summary
The facility failed to ensure that diagnostic practices met professional standards for two residents, leading to inaccuracies in their medical records. Resident #66 was admitted with a diagnosis of bipolar disorder, but their medical record inaccurately included a diagnosis of schizophrenia. This discrepancy was not addressed in the Preadmission Screening/Annual Resident Review (PASARR) or the behavioral services notes. Interviews with the Social Work Director, Unit Manager, and Regional Clinical Director revealed uncertainty and acknowledgment of the inaccuracy, but no corrective information was provided before the survey exit. Resident #64's medical record also contained inaccuracies. Although the resident was diagnosed with schizoaffective disorder bipolar type, the hospital discharge records did not support this diagnosis. The Minimum Data Set (MDS) inaccurately documented schizophrenia, and the PASARR indicated a diagnosis of bipolar disorder. Interviews with the Social Worker and Nursing Home Administrator revealed a lack of verification of diagnoses with hospital records and an error in the computerized system that automatically listed schizoaffective disorder bipolar type instead of bipolar disorder. The deficiencies in diagnostic practices were highlighted by the facility's failure to accurately document and verify residents' diagnoses. The inaccuracies in the medical records of both residents were acknowledged by the Regional Clinical Director, who noted that the computerized system contributed to the errors. The facility's staff did not provide explanations for the discrepancies, and the necessary corrections to the residents' diagnoses records and MDS were not made before the survey exit.
Failure to Provide Adequate Oral Hygiene for Resident
Penalty
Summary
The facility failed to provide adequate daily oral hygiene for a resident who required assistance with activities of daily living. The resident, who was cognitively intact and had diagnoses including anxiety and depression, was observed multiple times with caked debris on their lower teeth and severe halitosis. Despite the care plan and kardex indicating that oral hygiene should be performed every shift and as needed, the resident's oral care was neglected. Interviews with staff revealed that the midnight shift was responsible for the resident's morning care, and the resident was cooperative with assistance. However, the resident reported not receiving the necessary oral care supplies and assistance, stating that staff claimed they did not have time to help. The resident's clinical record showed that they had been seen by a dentist twice, with findings of calculus and plaque buildup, and recommendations for staff assistance with daily hygiene. Despite these recommendations, the resident continued to experience inadequate oral care, as evidenced by the persistent debris and halitosis. The Registered Nurse/Unit Manager acknowledged the need for oral care after meals, at night, and as needed, but offered no explanation for the lack of care provided. The resident expressed dissatisfaction with the situation, highlighting a lack of necessary supplies and assistance for oral hygiene over several weeks.
Failure to Follow Physician's Orders and Properly Position Residents
Penalty
Summary
The facility failed to follow a physician's order and appropriately position two residents, leading to potential unmet care needs. Resident #67, a cognitively intact female with multiple sclerosis and recent right shoulder replacement, was not administered Trazodone as recommended by a psych consult for adjustment insomnia. Despite the recommendation being made on 12/19/24, the order was not added to the electronic medical record until 1/06/25. Interviews with the Director of Nursing, Unit Manager, and Social Worker revealed a breakdown in communication and process, as the consult notes were not reviewed or acted upon in a timely manner. Resident #6, who has severe cognitive impairment and left-sided hemiparesis, was observed multiple times sitting in a high-back wheelchair with feet dangling, indicating improper positioning. The footrests were attached, but the resident's feet did not reach them, which was not noticed by the Registered Nurse/Unit Manager. The therapy department was responsible for assessing and issuing the wheelchair, but no assessment or fitting documentation was provided by the end of the survey.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy medication recommendations were followed up by the physician for two residents. Resident 41 was admitted with a diagnosis of a sacrum fracture and was prescribed three pain medications: Tylenol, Oxycodone, and Tramadol. A pharmacy recommendation dated 11/28/2024 requested clarification on which medication should be used for mild, moderate, and severe pain. However, there was no physician follow-up on this recommendation, as confirmed by the Director of Nursing during an interview. Resident 66, admitted with diagnoses including GERD, diabetes, and COPD, had a physician's order for Metformin and Glycopyrrolate. A pharmacy recommendation on 11/12/2024 suggested providing a diagnosis for Glycopyrrolate and adjusting the timing of Metformin administration. These recommendations were not addressed, and no documentation from the physician explained why. The Director of Nursing and Regional Clinical Director noted that the facility had 30 days to act on recommendations, but the resident's hospitalization from 11/26/24 to 11/29/24 was cited as a factor in the oversight.
Medication Administration and Antibiotic Selection Deficiencies
Penalty
Summary
The facility failed to ensure that medications were administered within the prescribed parameters for Resident #66, who was admitted with a diagnosis of hypertension. The physician's order specified that Lisinopril should be held if the resident's systolic blood pressure was less than 110. However, the medication was administered on three occasions when the resident's systolic blood pressure was 108. The Unit Manager acknowledged the error but could not explain why the medication was administered against the order. For Resident #45, the facility failed to administer the appropriate antibiotic for a urinary tract infection. The resident, who had multiple diagnoses including a subarachnoid hemorrhage and severe cognitive impairment, was initially prescribed Bactrim DS. However, a urine culture later revealed that the bacteria were resistant to this antibiotic. Despite receiving the culture results on December 31, 2024, the facility did not change the antibiotic until January 2, 2025. The Clinical Care Coordinator explained that the delay was due to her absence over the holiday and that she only reviewed the results upon her return. The Corporate Director of Infection Control confirmed that the facility was expected to follow the McGeer Criteria for infection screening and that a risk-benefit analysis should be conducted if these criteria were not followed. However, no such analysis was found for Resident #45. The Director also stated that nursing staff were expected to notify medical providers of test results promptly, which did not occur in this case, leading to a delay in administering the appropriate treatment.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was attempted for a resident in order to reduce the use of a psychotropic medication. The resident was admitted to the facility and was prescribed Prozac 40 mg for depression and bipolar disorder. Despite a note in the behavioral health services Physician's notes indicating that a GDR would be attempted and documented in the resident's chart, no GDR was ordered or attempted. The resident's medication administration record showed that the Prozac dosage remained unchanged from the initial prescription date. Additionally, the resident had not been seen by behavioral health services since the date when the GDR was supposed to be considered. During an interview, a social worker acknowledged that the GDR had not been attempted and confirmed the lack of follow-up by behavioral health services. The social worker also noted that the resident should have been seen monthly by behavioral health services, indicating a lapse in the facility's protocol for managing psychotropic medications and behavioral health follow-up.
Failure to Provide Timely Dental Services for a Resident
Penalty
Summary
The facility failed to ensure timely dental services for a resident, identified as R7, who was admitted with diagnoses including congestive heart failure, diabetes, and dementia. R7 had severe cognitive impairment and was receiving hospice services. The Minimum Data Set (MDS) assessments indicated that R7 had a broken or loosely fitting full or partial denture from March to December 2024. Despite this, the facility did not facilitate the timely repair or replacement of R7's dentures. Observations and interviews revealed that R7's upper denture had been broken since April, and the bottom denture was lost, yet the dentures had not been replaced. The facility's social services and dental service provider communications were inadequate, leading to delays in dental care. A social service note from February 2024 indicated that a referral was made to a dental service provider, but the provider had not seen R7. Subsequent notes revealed that the dental provider could not repair the dentures as they were not originally provided by them. Despite impressions being taken in October 2024, there were no further dental notes, and R7 remained without dentures. The Social Work Director was unable to explain why R7 was not seen by the dentist in December, despite being on the list for dental visits, highlighting a lack of coordination and follow-up in providing necessary dental care for R7.
Unsanitary Incontinence Care
Penalty
Summary
The facility failed to ensure incontinence care was provided in a sanitary manner for Resident #6. Resident #6, who had severe cognitive impairment and was frequently incontinent of bladder and occasionally incontinent of bowel, was observed to have been cleaned improperly by CNA D. Confidential Staff F reported that CNA D dipped a cloth with feces on it into the toilet, rinsed it in the sink, and then used the same cloth to wash Resident #6's buttocks. Despite being told by CS F to stop, CNA D continued to use the cloth on the resident. During a phone interview, CNA D admitted to the unsanitary practice, explaining that she believed the water in the toilet was the same as the water from the sink. CNA D, who had been a CNA for eight years and employed by the facility for four months, was on suspension at the time of the interview. She acknowledged that her actions were wrong and that she no longer considered toilet water to be clean and sanitary.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
