Harbor Post Acute Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wyoming, Michigan.
- Location
- 2060 Health Drive, Wyoming, Michigan 49519
- CMS Provider Number
- 235723
- Inspections on file
- 23
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Harbor Post Acute Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease and a recent hip fracture was able to leave the building and was later found standing outside near a stairwell door, dressed for cold weather but without shoes. Earlier that evening, an RN had heard a second-floor door alarm and silenced it without investigating the cause. The alarm had been triggered by the resident’s exit, and the lack of follow-up allowed the resident to remain outside unsupervised until staff discovered her, constituting a failure to prevent elopement and ensure adequate supervision.
A resident with a pressure ulcer experienced deterioration due to inadequate care at an LTC facility. The resident was not repositioned overnight, and her wound was left exposed without a dressing after a shower. Staff failed to update treatment orders to use wound cleanser instead of soap and water, as recommended by a wound specialist. The wound worsened, requiring urgent hospital intervention. Interviews revealed non-compliance with professional care standards.
A resident admitted with chronic conditions did not receive all prescribed medications timely due to delays in entering medication orders and lack of communication with the medical provider. The facility failed to utilize backup medication resources, resulting in missed doses, contrary to its policy requiring timely administration and documentation.
The facility failed to label chemical spray bottles and maintain water filters and cleanliness in food preparation areas, risking food contamination. Unlabeled spray bottles and undated water filters violated FDA codes, while dirt and debris in kitchenettes and ice machine build-up indicated inadequate cleaning, potentially affecting 52 residents.
A facility failed to implement its smoking policy for a resident who was observed with smoking materials in his room and smoking in a non-designated area. Additionally, a resident requiring assistance with transfers was moved by a single CNA, contrary to the care plan requiring two staff members. These deficiencies indicate a lack of adherence to policies, potentially compromising resident safety.
The facility failed to maintain respiratory equipment for four residents, including those with COPD and chronic respiratory failure. Observations revealed uncovered and improperly stored nebulizer and oxygen equipment, contrary to facility policy. This deficiency highlights a lack of adherence to procedures for safe respiratory care.
An LPN pre-poured medications for eight residents and documented their administration before they were given, violating the facility's medication administration policies. The DON and UM confirmed that medications should be administered at the time they are prepared, and the incident was identified during an observation of the medication pass.
The facility failed to properly assess and monitor two residents for self-administration of medication. One resident had access to an inhaler and Flonase without documented assessment or monitoring, while another resident, deemed safe to self-administer, did not document usage or have a physician order for self-administration. The facility's policy on medication self-administration was not followed, leading to deficiencies in medication management practices.
A resident with end-stage renal disease and CHF experienced significant weight gain, but the facility failed to notify the physician or measure abdominal girth as ordered. Despite policies requiring timely notification of condition changes, these were not followed, leading to a deficiency in care.
A resident was prescribed Risperidone without a documented diagnosis or rationale, despite not having a mental illness or dementia. The resident, who was moderately cognitively impaired and admitted with conditions like Covid-19 and COPD, exhibited wandering behaviors but was easily redirected. The facility's policy did not support antipsychotic use for such behaviors, and there was no behavior monitoring or behavioral health consultation, leading to a deficiency.
A facility failed to ensure proper PPE use for a resident under Enhanced Barrier Precautions. The resident required assistance with activities like transferring and toileting, which mandated gown and glove use. However, a CNA was observed not using PPE during a transfer, misunderstanding the requirement as only necessary for wound care. The LPN Unit Manager confirmed that PPE is required for all high-contact care activities, aligning with the facility's policy.
The facility failed to provide essential information to residents and their representatives regarding Medicaid/Medicare coverage, state agency contacts, and procedures for filing complaints and grievances. This deficiency affected all residents, as confirmed by interviews and record reviews. The Nursing Home Administrator admitted the lack of admission packets and policies for re-admitting residents after hospitalization, leading to confusion and stress for residents and their representatives.
The facility lacked an admission policy and failed to provide admission packets to residents, leaving them uninformed about their rights, costs, and bed hold policies. This deficiency was confirmed through interviews and record reviews, with the Nursing Home Administrator acknowledging the absence of necessary documentation and information for residents.
The facility failed to properly plan for the discharge of two residents, leading to unsafe discharges and the inability to readmit one resident post-hospitalization. One resident was discharged home without adequate support, resulting in a return to the hospital, while another faced financial and communication issues due to a lack of information about insurance and Medicaid resources. The facility's focus on being a Sub-Acute Rehab (SAR) rather than accommodating long-term care needs contributed to these deficiencies.
The facility failed to notify the Office of the State LTC Ombudsman about resident discharges as required by their policy. Despite the policy mandating written notification to the Ombudsman for all discharges, the facility did not report any facility-initiated discharges over the past ten months. The Nursing Home Administrator acknowledged the absence of a discharge notification list, and the LTC Ombudsman confirmed the last report was in mid-2023. The Director of Nursing only sought clarification on the regulation the day before the survey began.
The facility failed to provide Bed Hold policies to residents upon admission and during transfers, affecting all residents. Interviews and record reviews showed that 12 residents did not receive the necessary documentation, leading to confusion and distress for residents and their representatives. The Nursing Home Administrator admitted that admission packets did not include the Bed Hold policy.
The facility's telephone communication system was ineffective, preventing a resident's DPOA from reaching the resident and staff. The DPOA experienced issues with calls not being received in the resident's room and difficulties contacting the front desk and charge nurse. Staff interviews revealed problems with the phone system, including accidental activation of the 'Do Not Disturb' button and challenges in transferring calls. The NHA was unaware of these issues and reported no records of related concerns.
A resident's DPOA was not provided with necessary information on applying for Medicare and Medicaid benefits, leading to delayed Medicaid coverage and significant out-of-pocket expenses. The resident, with serious health conditions, faced financial stress when Medicare ended, and the facility attempted to discharge them despite needing two-person care. The facility failed to assist with Medicaid paperwork timely, resulting in a $14,000 bill, and did not have a policy for readmitting residents post-hospitalization.
A resident with Parkinson's disease and other conditions was not readmitted to the facility after hospitalization due to pending Medicaid status and lack of a payor source. The facility, designed for Sub-Acute Rehab, did not provide necessary information on bed hold policies or assist in timely Medicaid application, leading to the resident's placement in another facility.
The facility failed to provide adequate care for pressure ulcers for two residents, who required repositioning and wound vac care. One resident was not repositioned as needed, with missed dressing changes and no documentation of refusals or physician notification. The other resident's wound vac was not functioning due to refusal to be turned, and standard procedures for non-functioning wound vacs were not followed. The lack of documentation and communication led to a deficiency citation.
Failure to Prevent Elopement After Door Alarm Was Silenced Without Investigation
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and ensure adequate supervision to prevent accidents for a resident with known cognitive impairment. The resident was an elderly female with a recent hip fracture and Alzheimer’s disease who reported remembering being outside the building but could not explain why she had gone out. On the evening of the incident, she was found standing outside the facility next to the southeast stairwell door. At that time, she was dressed appropriately for the cold weather except for having only one sock and no shoes. A head-to-toe assessment was completed and revealed no concerns of physical harm, and the resident later stated she was not harmed, felt safe, and would not repeat the behavior. The events leading to the deficiency included a failure by staff to appropriately respond to a door alarm. At approximately 9:00 PM, an RN heard the second-floor door alarm sounding and silenced the alarm without further investigating the cause. About 15 minutes later, the resident was discovered outside near the stairwell door, indicating that the alarm had signaled an actual exit attempt that was not properly assessed. This sequence of events shows that the resident was able to leave the building unsupervised, resulting in an elopement and demonstrating that the area was not kept free from accident hazards with adequate supervision at the time of the incident.
Failure in Pressure Ulcer Care Leads to Resident Harm
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for a resident, resulting in the deterioration of the resident's condition. The resident, who was cognitively intact and required assistance with toileting and repositioning, reported that the night shift CNA did not check or reposition her between 10:00 PM and 6:00 AM, leaving her brief soaked. Observations confirmed that the resident's wound was exposed without a dressing, and her brief was wet with urine. The LPN responsible for replacing the dressing after the resident's shower was too busy to do so, leaving the wound exposed for an extended period. The facility's staff did not follow the updated treatment orders for the resident's pressure ulcer. The wound specialist had recommended using wound cleanser instead of soap and water due to the wound's worsening condition. However, the staff continued to use soap and water, as the order was not updated in the electronic medical record. This oversight contributed to the deterioration of the resident's wound, which increased in depth and required urgent surgical intervention. Interviews with the facility's staff revealed a lack of adherence to professional standards of practice for pressure ulcer care. The LPN Unit Manager acknowledged that the dressing should be replaced immediately after a shower, and the Wound RN admitted to not updating the treatment order as recommended by the wound specialist. The Wound Specialist PA confirmed that the wound had worsened significantly and required hospital intervention, highlighting the facility's failure to provide appropriate care and prevent further harm to the resident.
Failure to Administer Medications Timely Upon Admission
Penalty
Summary
The facility failed to provide timely medication administration for a resident upon admission, which did not meet professional standards of practice. The resident, who was admitted with chronic obstructive pulmonary disorder and diabetes, reported not receiving all prescribed medications since admission. The Licensed Practical Nurse (LPN) responsible for the admission noted that the process of entering the resident's extensive medication list into the computer delayed the pharmacy delivery, resulting in medications being delivered later than expected. Consequently, several medications, including Aggrenox, carbamazepine, fiber capsules, Mometasone inhaler, and lamotrigine, were not administered as scheduled on the evening of admission. Further investigation revealed that the facility's nursing staff did not utilize available backup medication resources or notify the on-call medical provider about the unavailability of medications, as per facility policy. The LPN Unit Manager confirmed that some medications were available in the backup medication cart but were not administered, and there was no documentation of communication with the medical provider regarding the missed doses. The facility's policy requires medications to be administered within 60 minutes of the scheduled time and mandates documentation of reasons for any missed doses, which was not adhered to in this case.
Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper labeling and maintenance of equipment and cleanliness in food preparation areas, which could lead to food contamination and increased risk of foodborne illness. During a follow-up kitchen inspection, a working chemical spray bottle was found unlabeled, violating FDA 2017 Food Code Section 7-102.11, which requires that working containers for storing poisonous or toxic materials be clearly identified with the common name of the material. Additionally, water filters for the Combi Oven and ice machines were either undated or improperly labeled, failing to comply with FDA 2017 Food Code Section 5-205.15, which mandates that plumbing systems be maintained in good repair. Further observations revealed that the 2nd and 3rd floor kitchenettes/pantries had dirt and debris under equipment and along floor/wall junctures, and cooler doors and seals required cleaning to remove build-up. The 3rd floor ice machine had a slight pink/orange slime build-up, and the 2nd floor ice machine had scale build-up, indicating a failure to clean as often as necessary to prevent accumulation, as required by FDA 2017 Food Code Sections 6-501.12 and 4-602.13. These deficiencies potentially affected 52 residents who consume food from the kitchen and kitchenettes/pantries.
Failure to Implement Smoking Policy and Transfer Procedures
Penalty
Summary
The facility failed to implement its smoking policy and procedure for a resident who was reviewed for smoking. The resident, who was cognitively intact, was observed with cigarettes and a lighter in his room, contrary to the facility's policy that required smoking materials to be kept at the nursing station. The resident reported not being required to sign out when leaving the unit to smoke, and was observed smoking in a non-designated area outside the facility's front door, despite a no-smoking sign being present. Interviews with staff revealed inconsistencies in the enforcement of the smoking policy, with some staff indicating that the resident's smoking supplies were kept locked in his room, contrary to the policy. The facility also failed to ensure that residents were transferred according to their current care plan. A resident, who was cognitively intact and required assistance with transferring, was observed being transferred by a Lead CNA using a sit-to-stand lift without the assistance of another staff member, despite the care plan indicating that two staff members were required for such transfers. The Lead CNA acknowledged that the transfer was not in accordance with the care plan, and the LPN Unit Manager confirmed the requirement for two staff members during transfers. These deficiencies highlight a lack of adherence to established policies and procedures regarding smoking and resident transfers, potentially compromising resident safety and well-being. The discrepancies between the facility's stated policies and actual practices were evident in both the handling of smoking materials and the execution of resident transfers, as observed and reported by staff members.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment according to professional standards for four residents requiring respiratory care. Resident #26, diagnosed with chronic respiratory failure and COPD, had nebulizer equipment that was uncovered and appeared used, with droplets visible, and was sometimes cleaned by staff. Resident #27, with acute respiratory failure and COPD, had oxygen tubing hanging loose and unsecured, with no maintenance orders for the equipment. Resident #43, diagnosed with COPD, asthma, and emphysema, had nebulizer equipment that was uncovered and visibly dirty, and oxygen tubing was not stored properly. Resident #48, with end-stage renal disease and congestive heart failure, had oxygen tubing improperly draped and was not wearing supplemental oxygen during an interview. The facility's policy on respiratory therapy equipment outlined specific procedures for maintaining and storing oxygen and nebulizer equipment, including changing oxygen cannula and tubing every seven days, storing equipment in plastic bags when not in use, and cleaning nebulizer equipment after use. However, these procedures were not followed for the residents observed, leading to deficiencies in the care and maintenance of respiratory equipment. The lack of adherence to these procedures was evident in the observations and interviews conducted with the residents, highlighting a failure to ensure safe and appropriate respiratory care.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that licensed personnel adhered to medication administration policies and procedures, as evidenced by an incident involving an LPN who pre-poured medications for eight residents. During an observation, it was discovered that medications had been preset in plastic medication cups with paper cups placed over them, each marked with a number corresponding to room numbers. The LPN admitted to pre-pouring the medications and had already documented their administration in the Medication Administration Records (MARS), despite the medications not being given to the residents. The Director of Nursing (DON) and Unit Manager (UM) confirmed that the facility's policy prohibited pre-pouring medications and that medications should be administered at the time they are prepared. Upon further investigation, it was revealed that the LPN had documented the administration of these medications in the electronic MAR before they were actually given. The DON and UM took steps to correct the documentation and ensure the medications were properly administered, but the initial failure to follow protocol resulted in a deficiency.
Deficiency in Medication Self-Administration Assessment and Monitoring
Penalty
Summary
The facility failed to ensure proper assessment and monitoring for self-administration of medication for two residents, R20 and R26. R20, who was admitted with asthma and respiratory failure, was observed with an albuterol inhaler and Flonase on her over-the-bed table, which she reported having immediate access to since admission. Despite a policy requiring an interdisciplinary team assessment for self-administration, no documentation was found in R20's electronic medical record (EMR) indicating such an assessment had been conducted. Additionally, the medication administration record (MAR) did not reflect any self-administration documentation, and R20 reported using the inhaler several times a day without being asked by nursing staff about its usage. R26, admitted with chronic respiratory failure and COPD, had a completed self-administration evaluation deeming her safe to self-administer inhaled medications. However, observations revealed that R26 kept her inhaler at the bedside and used it up to four times a day without documenting its use or being asked by nurses about the frequency of use. The MAR did not indicate any PRN doses taken, and there was no physician order for R26 to self-administer inhaled medications. Furthermore, R26 reported not rinsing her mouth after using the medications, which was not addressed by the nursing staff. The facility's policy on self-administration of medications requires nursing staff to determine responsibility for ensuring medication intake, secure storage of medications, and documentation of self-administered doses in the MAR. However, these procedures were not followed for R20 and R26, leading to deficiencies in the facility's medication management practices. The Director of Nursing acknowledged the lack of documentation and indicated that such assessments should be present in the EMR and MAR, but no additional information was provided by the facility by the time of the survey exit.
Failure to Monitor and Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to adequately assess, monitor, and notify the physician of clinical changes in condition for a resident with end-stage renal disease and congestive heart failure. The resident was admitted with a care plan that included monitoring vital signs and notifying the physician of any abnormal readings, as well as monitoring changes in lung sounds, edema, and weight. Despite these directives, the facility did not measure the resident's abdominal girth as ordered, nor did they notify the physician of significant weight gains, which were critical indicators of the resident's heart failure condition. The resident experienced a significant weight gain of over 12 pounds in two days, which was not communicated to the physician. The Registered Dietitian, who was responsible for monitoring resident weights, did not note the weight gain on the monitoring spreadsheet. Additionally, the resident reported that nursing staff had not been measuring his abdominal girth, a key intervention for managing his condition. The Registered Nurse confirmed that there was no evidence of physician notification regarding the weight gains, and the Director of Nursing was unaware of why these critical assessments were not being performed. The facility's policies required timely notification of the physician and responsible parties in the event of significant changes in a resident's condition. However, these policies were not followed, as evidenced by the lack of documentation and communication regarding the resident's weight changes and abdominal girth measurements. This oversight in monitoring and communication contributed to the deficiency in providing appropriate care for the resident's complex medical needs.
Inappropriate Prescription of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that antipsychotic medications were prescribed appropriately for a resident, as there was no documented diagnosis or rationale for the use of Risperidone in the clinical record. The resident, who was admitted with conditions including Covid-19, acute respiratory failure, COPD, and a cognitive communication deficit, was moderately cognitively impaired. Despite not having a mental illness or dementia diagnosis, the resident was prescribed Risperidone for agitation without documented behavioral health diagnoses or a consultation with behavioral health providers. The care plan indicated the use of antipsychotic medications but lacked associated diagnoses. The resident exhibited wandering behaviors but was described as pleasant and easily redirected, with no significant behavioral concerns noted in the progress notes. The facility's policy specified conditions for antipsychotic use, which did not include wandering or non-dangerous agitated behaviors. The LPN Unit Manager confirmed that there was no behavior monitoring in place and that the resident's wandering was understandable due to unfamiliarity with the facility. The facility's failure to document a valid reason for the antipsychotic prescription and lack of behavior monitoring contributed to the deficiency.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) for a resident under Enhanced Barrier Precautions. Resident #37, who was admitted with chronic obstructive pulmonary disorder and peripheral vascular disease, was cognitively intact and required assistance with various activities such as toileting, transferring, and repositioning. The resident's care plan and physician's orders mandated the use of gown and gloves during high-contact care activities, including dressing, bathing, transferring, and toileting, to prevent the transmission of multidrug-resistant organisms. During an observation, a Lead Certified Nursing Assistant (CNA) was seen transferring Resident #37 without donning the required gown and gloves, despite signage indicating the need for enhanced barrier precautions. The CNA mistakenly believed that these precautions were only necessary during wound care. This misunderstanding was clarified by the Licensed Practical Nurse (LPN) Unit Manager, who confirmed that gown and glove use is required for all high-contact care activities for residents on enhanced barrier precautions. The facility's policy, reviewed in December 2020, supports this requirement, emphasizing the use of PPE during specific high-contact activities to prevent the spread of infections.
Failure to Provide Essential Admission Information
Penalty
Summary
The facility failed to provide residents with necessary information regarding Medicaid/Medicare coverage, state agency contacts, advocacy groups, and procedures for filing complaints and grievances. This deficiency was identified through interviews and record reviews involving four residents. The Power of Attorney for one resident reported not receiving an admission packet with information on Medicaid procedures or state agency contacts, leading to confusion when the facility refused to re-admit the resident after hospitalization. Another resident's Designated Power of Attorney also did not receive an admission packet, which resulted in a lack of resources to apply for Medicaid timely and understand bed hold policies, causing stress during the financial process. Additionally, two other residents reported not receiving information about bed hold policies upon admission. The Nursing Home Administrator acknowledged the facility's limited bed availability and the lack of a policy for re-admitting residents after hospitalization. The administrator also confirmed that the facility does not provide admission packets, except for the Admission Agreement, which contributed to the residents' and their representatives' lack of awareness about important procedures and resources.
Deficiency in Admission Policy and Procedure
Penalty
Summary
The facility failed to have an admission policy and procedure in place, resulting in residents being uninformed of their rights and resources. This deficiency was identified through interviews and record reviews for three residents. The Designated Power of Attorney for one resident reported not receiving an admission packet, which led to a lack of information about insurance, Medicaid resources, costs, fees, and bed hold policies. This lack of information caused financial stress and complications, as the resident was not allowed back to the facility after a hospital transfer due to unawareness of the bed hold policy. The Nursing Home Administrator confirmed the absence of an admission policy and the lack of admission packets for residents, which should include information on rights, bed hold policies, costs, and services. The facility only had a Consent to Treat & Admission Agreement, and the administrator was temporarily handling business office duties due to a vacancy. The review of electronic medical records for the residents revealed no Consent to Treat or Admission Agreement on file, further indicating the deficiency in the facility's admission process.
Inadequate Discharge Planning and Readmission Issues
Penalty
Summary
The facility failed to adequately prepare for the discharge of two residents, resulting in unsafe discharges and the inability to readmit one resident post-hospitalization. Resident #4, who was moderately cognitively impaired and required assistance with mobility and activities of daily living, was discharged home without proper support. Upon arrival at home, the resident was unable to care for himself, leading to a return to the hospital the following day. The discharge planning did not adequately consider the resident's needs for assistance, and the facility did not have a focus on discharge planning in the care plan. Resident #5, who had diagnoses including Parkinson's disease and congestive heart failure, was also discharged without proper planning. The resident's Durable Power of Attorney reported not receiving necessary information about insurance, Medicaid resources, or bed hold policies, which led to financial stress and complications in securing Medicaid. The facility attempted to discharge the resident when Medicare coverage ended, despite the resident requiring substantial assistance with ADLs. The facility did not provide a Notice of Medicare Non-Coverage or inform the resident's representative of the right to appeal the discharge decision. The facility's policies on discharge and transfer were not adequately followed, as evidenced by the lack of proper documentation and communication with residents and their representatives. The facility's focus on being a Sub-Acute Rehab (SAR) rather than accommodating long-term care needs contributed to the inadequate discharge planning and failure to readmit residents post-hospitalization. The facility did not have a policy on readmitting residents after hospitalization, and there was a lack of communication regarding bed hold policies and financial responsibilities.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to operationalize its policies and procedures regarding the notification of the Office of the State Long-Term Care Ombudsman about monthly discharges. The policy, dated January 1, 2023, mandates that residents and/or their responsible parties be notified in writing, in a language and manner they understand, prior to transfer or discharge. Additionally, the policy requires that the Ombudsman be notified via written communication of any discharge or transfer, with documentation related to the discharge or transfer included in the clinical record. However, the facility did not adhere to this policy, as evidenced by the lack of notification to the Ombudsman of all facility-initiated discharges over the past ten months. During an interview, the Nursing Home Administrator admitted that they did not maintain a list of LTC Ombudsman discharge notifications and had not reported discharges to the Ombudsman. An email from the LTC Ombudsman confirmed that the last Emergency Transfer Tracking reported was in June and July of 2023, with no communication of facility-initiated discharges since then. The Director of Nursing only reached out to the Ombudsman the day before the survey began to inquire about the regulation and the necessary information to proceed, indicating a significant lapse in compliance with the notification requirements.
Failure to Provide Bed Hold Policies to Residents
Penalty
Summary
The facility failed to provide Bed Hold policies to residents upon admission and during transfers to acute care or therapeutic leave, affecting all residents admitted to the facility. The deficiency was identified through interviews and record reviews, revealing that 12 residents did not receive the necessary documentation. The Notice of Bed Hold Policy, which should be signed by the patient or documented by the family or Designated Power of Attorney (DPOA), was not present in the Electronic Medical Records (EMR) for these residents. This lack of documentation indicates a systemic issue in the facility's admission and transfer processes. Specific cases highlight the impact of this deficiency. For instance, a resident with an acute condition was transferred to a hospital, and the facility refused to accept him back, leading to confusion and distress for the resident's Power of Attorney (POA). Another resident was not allowed to return after a hospital visit for a urinary tract infection, causing financial stress on the family. Interviews with residents and their representatives revealed a lack of awareness about the Bed Hold policy, and the Nursing Home Administrator admitted that admission packets did not include this policy, further contributing to the deficiency.
Deficient Telephone Communication System
Penalty
Summary
The facility failed to maintain an effective telephone communication system, impacting the ability of a resident's designated power of attorney (DPOA) to communicate with the resident and staff. The DPOA reported multiple instances where calls to the resident's room were not received, and attempts to contact the front desk resulted in an automated message without options to leave a message or redirect the call. The DPOA also experienced difficulties reaching the charge nurse, as calls to the facility would ring for extended periods without being answered, and attempts to contact the social worker resulted in poor call quality and disconnection. Interviews with facility staff revealed issues with the phone system, including problems with the 'Do Not Disturb' button being accidentally activated, preventing calls from going through. The Maintenance Director acknowledged a programming glitch in one room's phone system, which was resolved, but did not recall issues with the room where the resident resided. The LPN reported challenges in transferring calls to resident rooms and noted that the new phone system does not allow callers to leave messages if unanswered. The Nursing Home Administrator was unaware of the DPOA's communication issues and reported no records of concerns related to the phone system, although he acknowledged the facility's contract limitations with the current tech company.
Failure to Assist Resident with Medicaid Application
Penalty
Summary
The facility failed to provide necessary assistance and written information to a resident's designated power of attorney (DPOA) on how to apply for and use Medicare and Medicaid benefits. This resulted in the resident not having Medicaid coverage in a timely manner, leading to significant out-of-pocket expenses. The resident, who was admitted with diagnoses including Parkinson's disease, congestive heart failure, and cognitive communication deficit, faced financial challenges when Medicare coverage ended. The DPOA reported not receiving an admission packet with pertinent insurance and Medicaid information, leading to a stressful financial situation. The facility attempted to discharge the resident home, despite the resident requiring two-person assistance for care, and demanded advance payment for continued stay. The DPOA had to fill out Medicaid paperwork multiple times without assistance, resulting in a $14,000 bill. The facility's business office manager provided a Medicaid application only after receiving a check for three days of private pay. The facility did not have a policy for readmitting residents after hospitalization and did not provide admission packets. The resident's Medicaid application was delayed, and there was a lack of follow-up when Medicare coverage ended. The facility's regional business office manager consultant confirmed that the facility should have assisted the DPOA in applying for Medicaid sooner and that the NOMNC was not properly handled.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to readmit a resident, identified as Resident #5, after hospitalization, which resulted in the resident needing to find placement at another facility. Resident #5 was admitted to the facility with diagnoses including Parkinson's disease, congestive heart failure, and cognitive communication deficit. The resident was moderately cognitively impaired and required substantial to maximum assistance for most activities of daily living. The Designated Power of Attorney (DPOA) for Resident #5 reported not receiving an admission packet with information on insurance, Medicaid resources, costs, fees, or bed hold policies, which led to a lack of timely Medicaid application and awareness of bed hold policies. The facility's Social Worker informed the DPOA that Resident #5 would not be accepted back from the hospital as the resident required long-term care, which the facility was not equipped to provide. The Nursing Home Administrator (NHA) confirmed that the facility was designed for Sub-Acute Rehab (SAR) and not long-term care, and that Resident #5, who was pending Medicaid, would not have a payor source for readmission. The facility did not have a policy on permitting residents to return after hospitalization and did not provide admission packets upon admission. The Business Office Manager (BOM) and Regional BOM Consultant noted that Resident #5's Medicaid was pending upon discharge to the hospital, and the NOMNC (Notice of Medicare Non-Coverage) was not signed by the DPOA. The facility did not assist the family in applying for Medicaid in a timely manner. Additionally, there was no notice of transfer and discharge or bed hold policy on file for Resident #5, and the facility's bed hold policy document was not completed as required.
Deficient Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide adequate care and services for pressure ulcers for two residents, Resident #8 and Resident #6, who required repositioning, assessment, and monitoring, as well as daily dressing care and wound vac care. Resident #8 was observed multiple times throughout the day lying in the same position without being repositioned, despite having a care plan that required regular repositioning to relieve pressure from his ulcers. Interviews with staff revealed a lack of documentation regarding the resident's refusals to be repositioned, and there was no evidence that the physician was notified of these refusals. Additionally, there were missed dressing changes for Resident #8's pressure ulcers, with no documentation of reapproach or physician notification. Resident #6 was readmitted to the facility with an unstageable pressure ulcer and was supposed to have a wound vac in place. However, there were no wound care orders in place upon his readmission, and the wound vac was not functioning properly due to the resident's refusal to be turned. The facility's standard procedure for a non-functioning wound vac was not followed, as there was no alternative dressing applied to prevent further deterioration of the wound. The Director of Nursing acknowledged the challenges with the wound vac but could not provide documentation that the physicians were aware of the issues or that the resident did not receive wound care over the weekend. The facility's policies and care plans for both residents were not adequately followed, leading to deficiencies in the care provided for their pressure ulcers. The lack of documentation and communication regarding the residents' refusals and the non-functioning wound vac contributed to the failure to provide necessary treatments and interventions. This resulted in a deficiency citation for the facility, highlighting the need for improved adherence to care plans and policies to ensure proper wound care management.
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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