Healthsource Saginaw, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Saginaw, Michigan.
- Location
- 3340 Hospital Rd, Saginaw, Michigan 48603
- CMS Provider Number
- 235150
- Inspections on file
- 37
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Healthsource Saginaw, Inc during CMS and state inspections, most recent first.
A resident receiving therapy after a hip fracture reported that an unfamiliar LPN entered his room, did not verify his identity, and administered a handful of pills, a chocolate nutritional drink, and a nasal spray, despite the resident stating he did not receive a nasal spray and did not like chocolate drinks. The LPN was working an extra shift on an unfamiliar unit and later admitted she confused two side-by-side rooms occupied by residents with the same first name, giving one resident another resident’s BP and cardiac medications and intended IV antibiotic dose. The resident subsequently felt markedly “high” and informed staff and family, and review of records showed limited vital sign monitoring documented around the time of the error.
A cognitively impaired resident with Alzheimer’s, dementia, psychotic disturbances, and a history of agitation had an active care plan requiring 1:1 staff supervision for safety, but this intervention was not implemented. The resident, who required assistance with all ADLs, entered the adjacent room of another cognitively impaired resident with multiple neuropsychiatric diagnoses and agitation. Video showed a CNA seated in the hallway near both rooms using a personal cell phone while the first resident went unaccompanied into the second resident’s room, leading to the second resident yelling and being scratched in the face.
Two residents with the same first name were involved in a medication error when an LPN, working an unfamiliar assignment, entered the wrong room and administered a handful of oral medications, a chocolate nutritional supplement, and a nasal spray without using two identifiers or noting the absence of an ID bracelet. A cognitively intact resident with chronic kidney disease and recent hip fracture received another resident’s regimen, including Eliquis, Entresto, Jardiance, Lopressor, and spironolactone, in addition to his own scheduled medications, and later reported feeling lightheaded and "high." The intended recipient, a medically complex resident on IV Vancomycin with multiple cardiac and infectious diagnoses and DNR status, did not receive his prescribed doses. The facility’s policies required two-identifier verification and prohibited administering one resident’s medications to another, and its occurrence reporting policy required prompt reporting and investigation of medication-related incidents, but leadership became aware of the possible error only later in the day after staff notification.
The facility did not consistently implement fall prevention interventions as outlined in the care plans for two residents at risk for falls. Observations showed that required safety equipment, such as floor mats and accessible call lights, were not in place or within reach, and staff interviews confirmed these lapses. Both residents had recent falls, and the facility's protocols for individualized fall prevention were not followed.
A resident with a history of aphasia and cerebral infarction was found on the floor after an unwitnessed fall. A CNA observed the resident but left to attend to another upset resident, closing the door to the room. The resident's son later found his mother on the floor and became angry. Interviews revealed a lack of immediate assistance and communication among staff, contributing to the deficiency in care.
A resident with a history of falls and on anticoagulants experienced two falls shortly after admission to an LTC facility. Despite being identified as a high fall risk, the resident was inadequately supervised, leading to a fatal head injury. Staff interviews revealed communication gaps and insufficient monitoring, contributing to the incident.
A resident with multiple medical conditions developed a pressure ulcer that worsened over time due to the facility's failure to provide timely treatment and communicate with the physician. Despite signs of infection and deterioration, the facility did not initiate antibiotic treatment or report the condition to the physician, resulting in the resident developing sepsis and requiring hospital admission.
Two residents developed pressure ulcers due to inadequate preventive measures. One resident's ulcer was caused by bedding friction, and no pressure-relieving devices were used. Another resident's ulcer resulted from an AFO brace, with no initial order to monitor the skin. The facility failed to adhere to its pressure ulcer prevention policy.
The facility failed to make previous survey results and contact information for the State Hotline and Ombudsman accessible to all residents. The survey results binder was located in the front lobby, which was not easily accessible to all residents, especially those unable to travel the distance from the 500 hallway/nursing unit. Additionally, the contact information was placed at a height and in a format not accessible to residents in wheelchairs, leading to complaints during a Resident Council meeting.
The facility did not ensure that the daily staff posting was accessible to all residents, as it was only available at the front desk, located 580 feet from the main corridor of the 500 nursing unit. The DON confirmed that there were no individual postings for each nursing unit. Central Staffing emailed the staff posting to the switchboard operator, who printed it and placed it in a plastic file folder on the front counter, without posting it elsewhere.
The facility's kitchen, serving 162 residents, was found unsanitary with several deficiencies. Observations included a trash bin without a lid next to the grill, a microwave with dried food particles, and a can opener with dried food and chipping paint. Food items like shrimp, crackers, roast beef, and jelly lacked dates, and the brown sugar was expired. The facility failed to comply with its Food Storage policy and the 2017 FDA Food Code.
The facility failed to ensure a clean and safe environment across multiple units, with issues such as dirty CPAP machines, undated food items, and improper storage of medical equipment. Observations revealed dirty floors, incomplete temperature logs, and improper storage of personal items. The Director of Nursing and Director of Maintenance acknowledged these deficiencies, indicating a lapse in maintaining sanitary conditions as outlined in the facility's environmental services job description.
The facility failed to address resident grievances and did not invite all residents to the Resident Council meeting, leading to feelings of exclusion and frustration. Residents reported issues with staff behavior, including loudness, rude call light responses, and inadequate care. A Resident Council member felt deliberately excluded from a meeting with the state. The facility's records showed that several complaints were not documented or addressed, and the Director of Nursing was unaware of who was responsible for grievance follow-up.
The facility failed to provide a clean and homelike environment, with surveyors observing unclean conditions, improper storage of soiled clothes, and pest infestations in various areas. Residents expressed dissatisfaction with the use of plastic silverware and lack of condiments during meals. Staff acknowledged these issues, but immediate corrective actions were not evident.
The facility failed to provide adequate ADL care for several residents, resulting in hygiene issues such as long, dirty nails, unshaved facial hair, and unbrushed teeth. One resident reported delayed assistance with toileting, while another had severe cognitive deficits and was not receiving oral care despite having supplies. These deficiencies indicate a lack of adherence to care plans and responsibilities by CNAs.
The facility failed to honor the food preferences of four residents, leading to dissatisfaction and potential nutritional issues. One resident expressed dissatisfaction with the facility's food, citing issues such as excessive pepper and overcooked zucchini. Another resident reported not receiving cereal, which was a regular part of his diet, and being served fish despite having a seafood allergy. A third resident complained about overly spicy food and inadequate breakfast options, while a fourth resident expressed dissatisfaction with the food, opting for snacks or meals brought by family instead. The facility's policy on food and nutrition services aims to provide appropriate, attractive, and palatable food, but the residents' experiences indicate a failure to meet these standards.
The facility failed to provide adequate snacks for residents, leading to complaints about limited availability and variety. Residents, including diabetics, expressed frustration over the lack of healthy snack options and reliance on family for snacks. Observations confirmed minimal snack availability, with limited options like turkey sandwiches and a lack of fresh fruit.
The facility failed to follow infection control standards, with staff not adhering to proper PPE use, hand hygiene, and linen transport protocols. Observations included staff assisting residents without changing gloves or performing hand hygiene, and carrying clean linen against uniforms without barriers, increasing the risk of infection spread.
The facility failed to maintain resident dignity and privacy, as evidenced by inadequate privacy measures for a resident and delays in assistance. Residents reported dissatisfaction with delayed responses to call lights and inadequate grooming, leading to feelings of neglect and disrespect. Observations and interviews highlighted these deficiencies, with residents expressing frustration over the lack of timely and polite assistance.
The facility failed to incorporate PASARR Level II recommendations for specialized mental health services into the care plans of two residents with mental illness diagnoses. Despite having full cognitive abilities and requiring assistance with all care, the residents' care plans lacked any mention of specialized services. Interviews revealed a lack of communication with the Community Mental Health agency, and the facility's policy on coordinating assessments with the PASARR program was not followed.
The facility failed to update care plans for residents with complex needs, including a resident with multiple pressure ulcers and another with a history of falls and wandering. The care plans were outdated and lacked specific interventions, posing a risk of unmet care needs.
A resident with diabetes and other medical conditions experienced multiple episodes of low blood sugar, leading to hospitalization. The facility failed to monitor blood glucose levels properly and continued to administer insulin without notifying the physician, despite dangerously low readings. The care plan's instructions for managing diabetes were not consistently followed, contributing to the resident's deteriorating condition.
A facility failed to manage and monitor a resident's left arm splint, resulting in the resident having a soiled splint that had not been laundered. The resident, with a history of stroke and left-sided weakness, wore the splint at night. The Restorative Nurse noted that the splint was initially worn all the time but later changed to nighttime use. There was no clear responsibility for cleaning the splint, and a policy for hand splints was not provided. The care plan included assistive devices and skin checks but lacked details on splint usage and cleaning.
A resident with severe cognitive impairment and a history of combativeness sustained a laceration to the left eyebrow during a transfer using a Sara lift. The resident, who required assistance with all ADLs, exhibited aggressive behaviors earlier in the day. Despite this, the transfer was conducted by a single CENA, contrary to the care plan which did not specify the use of a mechanical lift.
A resident experienced significant weight loss due to the facility's failure to document food intake, provide suitable utensils, and notify the physician. The resident struggled with meal consumption due to impaired cognition and inadequate assistance, leading to numerous undocumented meals. Despite increased nutritional supplements, there was insufficient documentation of snack provision, and the physician was not informed of the weight loss.
The facility failed to properly clean, sanitize, and store respiratory equipment for residents, leading to potential cross-contamination and respiratory issues. A resident's CPAP machine was found dirty and not stored correctly, while another resident's oxygen concentrator was alarming with tubing on the floor, not supplying oxygen. Additionally, a third resident was observed with oxygen tubing in place, but the concentrator was not turned on, and the tubing was not dated as required by facility policy.
A resident with end-stage renal disease and dependence on dialysis was not properly monitored for changes at the dialysis port site, leading to the initiation of antibiotics due to drainage. The facility lacked a policy for assessing and monitoring dialysis ports, and staff confirmed that dressings were changed weekly or as needed. An order to monitor the port site was only established after the issue was identified.
A survey found that three medication carts in the facility were not properly cleaned, with crushed pills, paper, and dust present in the drawers. Interviews with nursing staff revealed confusion over cleaning responsibilities, with the DON indicating that second shift nurses were responsible. This lack of clarity contributed to the unsanitary conditions observed.
The facility failed to document the reason for antibiotic use and track antibiotic use for two residents, leading to potential inappropriate use. One resident was prescribed Doxycycline without a documented diagnosis, and another was given Bactrim for prophylaxis without a clear reason. The Infection Prevention and Control Nurse noted that the electronic medical record system did not allow for adding diagnoses with orders, and the facility's Antibiotic Stewardship policy was not effectively implemented.
A resident fell in the bathroom, sustaining facial fractures and subacute bilateral subdural hematomas. The facility failed to complete a comprehensive fall investigation, notify the physician of X-ray results, and provide timely medical intervention, leading to a significant delay in treatment.
Wrong-Medication Administration to Resident With Same First Name
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to adequate care and treatment during medication administration, resulting in the resident receiving another resident’s medications. The resident, who was in the facility for therapy after falling in his kitchen and cracking his hip, reported that a nurse who was not his regular nurse entered his room in the morning and gave him a handful of 4–5 pills, including a blue pill, along with a chocolate nutritional drink and a nasal spray. The resident stated the nurse did not ask his name, he had no ID bracelet on, and he told the nurse he did not receive a nasal spray and did not like chocolate nutritional drinks. He also reported that the nurse appeared to be looking for an IV port and IV equipment in his room, which he did not have, while a male resident in the next room with the same first name did have an IV pole. The resident later went to therapy, where his regular nurse brought his usual medications, prompting him to realize he had received extra medications earlier. He reported feeling lightheaded and “high,” describing the sensation as if he had smoked multiple marijuana cigarettes, and his brother, who was with him, commented that he looked high. The resident stated he informed staff, but he did not recall all details because he felt “out of it.” The facility’s investigative report documented that the family raised concerns about a medication error, and that the resident reported receiving medications from one nurse and then again from another nurse that same morning, both calling him by his first name, though he only recognized his regular nurse. In a subsequent interview, the LPN who passed the wrong medications explained she had picked up an extra shift on a unit where she did not usually work and was assigned a specific medication cart and room range. She stated that two residents with the same first name were in side-by-side rooms and that she mistakenly administered medications intended for one resident, including an IV antibiotic order, to the other resident. She acknowledged that she went to the wrong room and gave the wrong medications to the wrong resident, and that the other resident did not receive those medications. Vital sign records for the affected resident showed documentation at 1:37 a.m. and then not again until early evening that day, with no vital signs recorded around the time of the morning medication error.
Failure to Implement One-on-One Supervision Care Plan Resulting in Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement an active care plan intervention for one-on-one supervision for a cognitively impaired resident with a history of agitation and behavioral issues. Resident #103, a 79-year-old with Alzheimer’s, dementia, psychotic disturbances, agitation, and depression, had a BIMS score of 3 and required staff assistance with all ADLs. The resident’s behavioral care plan, dated 10/21/25, specified that the resident would have 1:1 staff supervision for safety, and this intervention had not been discontinued at the time of the incident. On the date of the incident, video review showed that Resident #103 left her room and entered the adjacent room of Resident #106 without being accompanied by staff, despite the active 1:1 supervision care plan. Resident #106, an 82-year-old with Alzheimer’s, dementia, Parkinson’s, schizophrenia, bipolar disorder, stroke, and agitation, also had a BIMS score of 3 and required assistance with all ADLs. According to the incident report, when Resident #103 entered Resident #106’s room, Resident #106 yelled for her to get out, and Resident #103 scratched him in the face. Video observation showed CNA C seated in the hallway next to both residents’ rooms, using her personal cell phone to text and scroll, with a portable computer positioned in a way that blocked her from the view of the nursing station. During this time, Resident #103 went into Resident #106’s room without intervention from CNA C. Interviews confirmed that Resident #103 was care planned for 1:1 supervision for safety at the time and that this intervention remained active and had not been discontinued, yet it was not being implemented when the resident-to-resident interaction and resulting scratches occurred.
Wrong-Resident Medication Administration Due to Failure to Verify Identity
Penalty
Summary
The deficiency involves the facility’s failure to prevent significant medication errors when an LPN administered a set of medications intended for one resident to another resident with the same first name. The facility’s own "Medication Administration General Guidelines" policy required that residents be identified using a minimum of two identifiers before medication administration and that medications supplied for a specific resident not be administered to others. During the incident, the nurse did not verify the resident’s identity with two identifiers, and the resident who received the wrong medications did not have an ID bracelet on his arm at the time. The nurse entered the wrong room and provided a handful of 4–5 pills, a chocolate nutritional supplement, and a nasal spray to the resident, who reported that he does not receive a nasal spray and does not like chocolate supplements. The resident who received the wrong medications (Resident #101) had been admitted with diagnoses including prosthetic left hip joint fracture, nondisplaced subtrochanteric fracture of the left femur, abnormal gait and mobility, chronic kidney disease, benign prostatic hyperplasia, and asthma. His MDS showed he was cognitively intact with a BIMs score of 15/15, and his advance directives indicated full code status. After receiving the medications, he reported feeling lightheaded and "high," describing feeling as if he had smoked multiple marijuana cigarettes, and stated he did not recall everything that happened because he was "out of it." He later informed staff that he believed he had received extra medications that morning. Vital sign documentation for him on the day of the incident showed a blood pressure of 113/70, pulse 95, and respirations 19 in the early morning, with no further vital signs recorded until the evening. The medications administered in error to Resident #101 were identified through pharmacy review as Eliquis 5 mg (anticoagulant), Entresto 24-26 mg (antihypertensive cleared through kidneys), Jardiance 10 mg (for diabetes/heart failure, cleared through kidneys), Lopressor 50 mg (beta blocker antihypertensive), and Spironolactone 25 mg (diuretic antihypertensive cleared through kidneys). These medications belonged to another resident (Resident #102), who had multiple serious medical diagnoses including MRSA, sepsis, bacteremia, pneumonia, long-term IV Vancomycin therapy, embolism and thrombosis, cardiomyopathy, left bundle branch block, tachycardia, heart failure, hypertension, hyponatremia, dysphagia, autistic disorder, epilepsy, anemia, and anxiety disorder, and whose advance directives indicated DNR status. The LPN involved acknowledged in interview that she made a mistake by giving the wrong medications to the wrong resident with the same first name and stated that the other resident did not receive his medications. The pharmacist, when asked if this constituted a significant medication error, stated it was a subjective, simple mistake and noted that resident rights of medication administration are a nursing issue at the point of administration. The facility’s occurrence reporting policy required reporting and investigation of medication-related incidents and harmful unintended results caused by taking medications, but the report documents that the ADON became aware of the possible medication error only later that evening after staff notification.
Failure to Implement Fall Prevention Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for fall safety prevention for two residents identified as being at risk for falls, accidents, and hazards. For one resident, who had a history of falls, dementia, and was receiving hospice care, the care plan required a blue floor mat to be placed next to the bed in the low position. However, multiple observations throughout the day revealed that the floor mat was not in place as required, instead being found leaning against the wall at the end of the bed. There was also no physician's order for a floor mat, despite the care plan directive. The Director of Nursing confirmed that the floor mat should have been in place according to the care plan. For another resident with severe cognitive impairment, Alzheimer's disease, and recent decline on hospice care, the care plan required the call light to be within reach at all times and a floor mat to be placed next to the bed. Observations over several days showed the call light was consistently coiled around the grab bar, out of the resident's reach, and the resident reported calling out for help instead of using the call light. The floor mat was also found folded and pushed away from the bed on one occasion. Staff interviews confirmed that the call light and floor mat were not positioned as required by the care plan, and that residents with limited ability to use call lights should be monitored more frequently. Record reviews indicated both residents had recent falls, and the facility's fall prevention program required individualized interventions to be implemented and monitored for effectiveness. Despite these protocols, the care plan interventions for fall prevention were not consistently followed, as evidenced by the observations and staff interviews.
Inadequate Post-Fall Assistance for Resident
Penalty
Summary
The facility failed to provide adequate post-fall assistance to a resident, resulting in feelings of sadness and tearfulness. The resident, who is non-verbal and has a history of aphasia, cerebral infarction, anxiety, and depression, was found sitting on a floor mat next to the bed after an unwitnessed fall. The incident occurred when a CNA observed the resident on the floor but chose to attend to another resident across the hall who was upset, leaving the resident unattended. The CNA closed the door to the resident's room to diffuse the situation between the resident and the other upset resident, which led to the resident's son entering the room and becoming angry upon finding his mother on the floor. Interviews with staff revealed that the LPN was in a nearby room and was alerted by yelling, while the CNA who initially found the resident on the floor did not stay with the resident or seek immediate help. Another CNA, who was the primary caregiver, was under the impression that the first CNA would stay with the resident. The Director of Nursing stated that the expectation is for staff to call for help and leave the resident in the position they were found until a nurse arrives. The lack of immediate assistance and communication among staff contributed to the deficiency in care provided to the resident after the fall.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to adequately supervise and prevent a fall for a resident with a known history of falls and anticoagulant use, resulting in a fatal incident. The resident, who was admitted to the facility from an assisted living environment, had a documented history of falls and was on medications with blood-thinning effects, such as Plavix and aspirin. Upon admission, the resident was assessed as a high fall risk due to factors including confusion, impulsivity, and the need for assistance with mobility. On the day of admission, the resident experienced two falls within a short period. The first fall occurred when the resident attempted to pick up spilled items from the floor, resulting in no visible injury. Despite being identified as a high fall risk, the resident was placed in a wheelchair and moved to the dining/day room due to restlessness. The second fall happened in this area, where the resident fell from the wheelchair, sustaining a significant head injury, including a large hematoma and bleeding. The staff's response to the resident's condition was inadequate, as there was a lack of consistent monitoring and documentation of neuro checks following the falls. The resident's condition deteriorated, leading to hospitalization and subsequent death due to complications from the head injury. Interviews with staff revealed a lack of clear communication and understanding of the resident's needs, contributing to the failure to prevent the falls and provide appropriate supervision.
Failure to Provide Timely Treatment for Pressure Ulcer
Penalty
Summary
The facility failed to provide timely treatment and care for a resident with a pressure ulcer, leading to severe complications. The resident, who had multiple medical conditions including diabetes, a history of stroke, and a tracheostomy, developed a pressure ulcer on the coccyx that worsened over time. Despite being at high risk for pressure ulcers, the facility did not adequately monitor or report the deterioration of the wound to the physician, resulting in the resident developing sepsis and requiring hospital admission. The facility's records indicate that the resident's pressure ulcer was first identified as a stage II wound, which later became unstageable with necrotic tissue and slough. Nursing notes documented the worsening condition of the wound, including increased size, foul odor, and bleeding, yet there was no evidence of timely communication with the physician or initiation of antibiotic treatment. The resident's condition continued to decline, with signs of infection such as fever and elevated heart rate, until they were eventually transferred to the hospital. Interviews with facility staff revealed a lack of appropriate action and communication regarding the resident's condition. The RN acknowledged a delay in treatment and failure to assess the situation adequately. The Infection Control Nurse and the Wound Nurse both admitted that they did not contact the physician despite the worsening condition of the pressure ulcer. The Director of Nursing and Assistant Director of Nursing recognized the issue as a significant problem, indicating a systemic failure in the facility's response to the resident's needs.
Failure to Prevent Pressure Ulcers in Residents
Penalty
Summary
The facility failed to prevent the development of pressure ulcers in two residents, resulting in discomfort and the need for ongoing wound care. Resident #415, who was admitted with multiple health issues including dementia and chronic pain, developed a pressure ulcer on the right heel due to shearing from bedding. Despite the wound care being performed according to orders, no pressure-relieving devices were used to keep the heel off the bed, which was a contributing factor to the ulcer's development. The facility's policy required the use of such devices, but this was not adhered to, as observed during the dressing change. Resident #75, admitted with conditions such as sepsis and rheumatoid arthritis, developed a pressure ulcer on the right heel due to friction from an ankle-foot orthosis (AFO) brace. Although the resident was provided with an air mattress and pillows to elevate the feet, there was no initial physician's order to monitor the skin around the AFO. The wound care nurse confirmed that an order should have been in place upon admission, but it was only entered after the issue was highlighted during the survey. The facility's policy on pressure ulcer prevention and treatment emphasizes the need to protect against pressure, friction, and shear, and to open a care plan for residents at risk. However, the lack of timely interventions and monitoring for both residents led to the development of pressure ulcers, indicating a failure to adhere to the established standards of care.
Inaccessible Survey Results and Contact Information
Penalty
Summary
The facility failed to ensure that previous survey results, State Hotline, and Ombudsman contact information were accessible to all residents. During a Resident Council meeting, members expressed their inability to locate the survey results and contact information for the Ombudsman and State Hotline. The survey results binder was located in the front lobby, which was not easily accessible to all residents, especially those who could not travel the .11 miles/580 feet from the 500 hallway/nursing unit to the lobby. Additionally, the contact information for the State Hotline and Ombudsman was placed at a height and in a format that was not accessible to residents in wheelchairs, as it was positioned approximately 5 feet high and not in large print. Interviews with the Director of Nursing (DON) and Activity Director (AD) confirmed the location of the survey results binder and the accessibility issues. The DON stated that the binder was visible to anyone entering through the front door, but did not acknowledge the distance issue. The AD noted that some residents were independent with their wheelchairs, but did not address the accessibility for all residents. An observation with the AD revealed that the contact information was not easily visible or readable for residents in wheelchairs, further contributing to the residents' complaints about not knowing how to contact the Ombudsman or access the State Hotline number.
Inaccessible Daily Staff Posting
Penalty
Summary
The facility failed to ensure that the daily staff posting was accessible for all residents, which could lead to residents being uninformed about the available staff. On a specific day, the staff posting was located at the front desk, which was .11 miles or 580 feet away from the main corridor hallway of the 500 nursing unit. The Director of Nursing confirmed that the staff posting at the front desk was for the entire building and that individual nursing units did not have their own postings. Central Staffing personnel indicated that they fill out the staff posting and email it to the switchboard operator daily. The switchboard operator then prints the posting and places it in a plastic file folder on the front counter, without posting it elsewhere in the building.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the Arbor Cafe's kitchen, which serves a census of 162 residents. During an inspection, several deficiencies were observed, including a large trash bin without a lid next to the grill, a microwave with dried food particles, and a large can opener with dried food and chipping paint. Additionally, a clean pan was found wet inside another pan, and a large trash bin was open behind baked cookies. The freezer floor had small pieces of food and papers, and various food items in the cooler and freezer were found without dates, including shrimp, crackers, roast beef, and jelly. Further observations revealed that a large white plastic container of corn starch had an excessive amount of corn starch on top and no dates, while the brown sugar container was expired. The toaster had an excessive amount of crumbs, and a large tray of uncovered fruit with no dates was found in the back refrigerator. In the dry storage room, an opened bag of noodles was found without dates. These findings indicate a failure to adhere to the facility's Food Storage policy and the 2017 FDA Food Code, which requires equipment food-contact surfaces and utensils to be cleaned when contamination may have occurred.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment across multiple units, including Wheels, Patriot, and Garden. During an environmental tour, several deficiencies were observed, such as a dirty CPAP machine and tubing not stored properly in a clear plastic bag, and an oxygen nasal cannula found on the floor. In the day room, a water/ice machine had calcium build-up, and opened food items without dates were found in the freezer. Additionally, a resident's refrigerator contained undated and partly used ice cream. The Director of Nursing indicated that dietary staff were responsible for cleaning neighborhood refrigerators. Further observations in the Patriot Neighborhood revealed towels and razors improperly stored, a dirty shower room floor, and a fan with dust-covered blades. Undated meat, cheese, and fish were found in a resident's refrigerator, and temperature logs were incomplete. In the day room, dirty brooms and a dustpan were left near confused residents. Similar issues were noted in the Garden Neighborhood and the Activity room, where undated food items were stored in refrigerators. The Director of Maintenance acknowledged that resident room refrigerators should be checked before use, but this was not done. The facility's environmental services job description emphasized maintaining clean and sanitary facilities, which was not upheld.
Failure to Address Resident Grievances and Exclusion from Meetings
Penalty
Summary
The facility failed to ensure timely follow-up on grievances and did not invite all residents to the Resident Council meeting, leading to feelings of exclusion and frustration among residents. During a Resident Council meeting, residents expressed dissatisfaction with the facility's response to their complaints, particularly regarding staff behavior. They reported that staff were loud in the hallways, responded rudely to call lights, and often did not return after canceling them. Residents also mentioned issues such as being left in soiled conditions, being forced to go to bed early due to staffing shortages, and missing church services for the same reason. A private interview with a Resident Council member revealed that they were not informed about a meeting with the state and felt deliberately excluded. The member expressed that they were often left out of meetings and believed it was because they were vocal about their concerns. The facility's records showed that several complaints raised in Resident Council meetings over the months were not documented or addressed, including issues with staff loudness, inadequate response to call lights, and concerns about staff training and shortages. The review of grievances over the past year indicated that the most recent concern form was from May 2024, which highlighted issues with call light response times and staff friendliness. However, the facility's response did not address the call light concern adequately. When questioned, the Director of Nursing was unaware of who was responsible for following up on council grievances, indicating a lack of accountability and oversight in addressing resident concerns.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unclean and cluttered conditions in various rooms and common areas. During a tour, surveyors noted a urine-soaked wash rag on the floor, strong odors of urine, and soiled clothes improperly stored under sinks, which posed infection control issues. Additionally, several rooms had visible dirt, food debris, and residue on shower curtains and caulking, along with missing drywall and laminate chips, contributing to an unkempt environment. The presence of pests, specifically spiders and webs, was observed in multiple areas, including resident rooms, the media center, and the main dining room. These areas also had piles of dead insects, and staff acknowledged the presence of spiders. The Environmental Services Director attributed the presence of silverfish to external factors but did not address the immediate pest control needs. The Director of Nursing was informed of the pest issue but did not take immediate action to resolve it. Residents expressed dissatisfaction with the dining experience, specifically the use of plastic silverware, which hindered their ability to eat meals comfortably. During resident council meetings, complaints were made about the lack of proper silverware and condiments, with residents having to use plastic utensils to cut through tough food items. Staff confirmed these issues, and the Hospitality Director acknowledged that new silverware had been ordered but did not explain why it was not yet in use, leading to ongoing resident dissatisfaction.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for several residents, resulting in various hygiene issues. Resident #135, who is non-verbal and has dementia, was observed with facial hair and dirty nails on multiple occasions. The care plan for this resident indicated that they should receive weekly nail care and assistance with shaving, but these needs were not met. An activity aide confirmed that certified nursing assistants (CNAs) are responsible for these tasks and acknowledged ongoing issues with nail care and shaving, which had been previously reported to the infection control nurse. Resident #59, who has full cognitive abilities but requires assistance with all care, reported that her call light was not answered timely, sometimes taking up to five hours for assistance. The resident's room had a strong smell of urine, and she mentioned that her blankets were not changed frequently enough. Her care plan included interventions for urinary tract infection prevention and assistance with toileting every two hours, which were not adequately provided. Resident #117, with severe cognitive deficits, was observed with unbrushed teeth despite having supplies brought in by a family member. The care plan indicated that the resident should receive assistance with oral care, which was not being provided. Additionally, Resident #60 and Resident #62 were observed with long, dirty nails and facial hair, respectively, despite care plans specifying regular nail care and assistance with facial hair removal. These observations highlight a pattern of neglect in providing essential ADL care to dependent residents.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of four residents, leading to dissatisfaction and potential nutritional issues. Resident #23 expressed dissatisfaction with the facility's food, citing issues such as excessive pepper, tough baked chicken, and overcooked zucchini. The resident also mentioned a lack of responsiveness to concerns since a previous chef left the facility. Resident #26 reported not receiving cereal, which was a regular part of his diet, and being served fish despite having a seafood allergy. The resident also noted a lack of menu options and inconsistent meal preparation. Resident #42 complained about overly spicy food and inadequate breakfast options, including dry toast without butter or jelly, despite being on a renal/carb consistent diet that allowed for sausage. The Registered Dietitian (RD) confirmed the resident's diet should have included sausage but was unsure why it was not provided. Resident #79 expressed dissatisfaction with the food, opting for snacks or meals brought by family instead. The RD acknowledged the resident's carb-consistent diet but had not followed up on her concerns due to being new to the facility. The facility's policy on food and nutrition services aims to provide appropriate, attractive, and palatable food, but the residents' experiences indicate a failure to meet these standards. The Director of Hospitality and the RD were aware of the issues but had not effectively addressed them, partly due to recent staffing changes. The lack of a Certified Dietary Manager and the newness of the RDs may have contributed to the oversight in addressing residents' dietary preferences and needs.
Inadequate Snack Provision for Residents
Penalty
Summary
The facility failed to provide adequate snacks, including bedtime snacks, for a group of residents, leading to complaints about the lack of availability and variety of snacks. Residents, including those with diabetes, expressed dissatisfaction with the limited snack options, such as the absence of healthy snacks like applesauce, peanut butter, fruit, or cheese. They reported having to rely on family and friends to bring in snacks, which caused feelings of frustration, sadness, and hunger. The residents also mentioned that the unit refrigerators were often empty, and there was no personal choice of snacks available. During observations and interviews, it was noted that the facility's snack provisions were inadequate. The Hospitality Director confirmed that residents could only access certain snacks without charge if they were included on their meal trays, otherwise, they would incur a cost. The floor stock list and always available menu were reviewed, revealing limited options such as turkey sandwiches and a lack of fresh fruit or other desired items. Observations of the Americana and Patriot cafes showed minimal snack availability, with one yogurt brought in by a family member and a sign indicating 'STAFF ONLY' access, further highlighting the deficiency in snack provision for residents.
Infection Control Deficiencies in PPE Use and Linen Handling
Penalty
Summary
The facility failed to adhere to Infection Prevention and Control standards, specifically in the use of Personal Protective Equipment (PPE), hand hygiene, and linen transport. On multiple occasions, staff members were observed not following proper protocols. For instance, a Certified Nursing Assistant (CENA) was seen assisting a resident with incontinence care and then offering a drink without removing dirty gloves or performing hand hygiene. Another CENA was observed leaving a resident's room without doffing PPE or performing hand hygiene before entering another room, and then returning to the original room with the same PPE. Additionally, issues were noted with the transport of clean linen. Staff members were seen carrying clean linen against their uniforms without using a barrier, which is against standard practice. Furthermore, another CENA entered a resident's room to assist with bed mobility and perineal skin observation without performing hand hygiene upon entry and improperly handled gloves by pulling them from their pocket without ensuring cleanliness. These actions demonstrate a lack of adherence to infection control protocols, potentially increasing the risk of infection spread among residents.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to maintain the dignity and privacy of its residents, as evidenced by several observations and interviews. Resident #56 was found exposed in their room without adequate privacy measures in place, as a nurse entered the room without ensuring the resident's body was covered. This lack of privacy was a direct violation of the resident's right to a dignified existence. Additionally, the facility did not provide timely and polite assistance to residents, as noted in the case of Resident #6, who expressed dissatisfaction with the delay in being assisted out of bed, and Resident #11, who reported that their call light was not within reach, leading to delays in receiving necessary help. The facility also failed to ensure proper grooming and personal hygiene for its residents. Observations revealed that female residents, such as Resident #135 and Resident #136, were not shaven, despite care plans indicating the need for assistance with facial hair. This neglect in personal grooming contributed to a lack of dignity and respect for the residents. Furthermore, Resident #28 was observed with unkempt hair and facial hair, indicating a failure to provide adequate grooming assistance as outlined in their care plan. The facility's response time to call lights was consistently delayed, as evidenced by the call light timing reports, which showed a significant percentage of call lights taking longer than the acceptable 15-minute response time. This delay in response was corroborated by the Resident Council meeting, where residents expressed frustration over the staff's failure to respond promptly to their needs. The combination of these deficiencies resulted in an environment where residents felt neglected and disrespected, leading to verbalizations of concern and anger, as well as feelings of shame and isolation.
Failure to Incorporate PASARR Recommendations for Specialized Mental Health Services
Penalty
Summary
The facility failed to incorporate recommendations for specialized mental health services from a Preadmission Screening and Annual Resident Review (PASARR) Level II assessment into the care plans of two residents. Resident #26, who was admitted with diagnoses including bipolar disorder and depression, had a PASARR Level II evaluation indicating the need for specialized mental health services. However, the resident's care plan did not include any mention of these specialized services, despite the resident having full cognitive abilities and requiring assistance with all care. Similarly, Resident #59, admitted with diagnoses such as bipolar disorder and a history of suicidal thoughts, also had a PASARR Level II evaluation recommending specialized mental health services. The care plan for this resident lacked any reference to a specialized mental health plan, even though the resident was on antidepressant and antipsychotic medications and had full cognitive abilities. Interviews with the facility's social worker revealed a lack of communication and follow-up with the Community Mental Health agency regarding the specialized mental health plans for both residents. The facility's policy on coordinating assessments with the PASARR program was not adhered to, resulting in the absence of specialized mental health services in the residents' care plans.
Failure to Update Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to update and revise individualized, person-centered care plans to reflect the changing care needs of three residents, leading to potential unmet care needs. Resident #16, who has a history of brain injury, quadriplegia, and multiple pressure ulcers, was observed with severe cognitive decline and dependency on all care. Despite having chronic and new wounds, the care plans for Resident #16 were outdated and did not include specific interventions identified by the wound nurse, such as the use of a low air loss mattress and heel boots. The care plans had not been updated to reflect the current wound status and necessary interventions. Resident #117, diagnosed with Alzheimer's disease and a history of falls, experienced multiple falls within the facility. The resident was found on the floor in other residents' rooms on several occasions, indicating a pattern of wandering. The fall care plan for Resident #117 was outdated and did not include interventions to address the resident's wandering behavior or the use of proper footwear, as recommended by the facility. The Assistant Director of Nursing noted that staff were to monitor the resident and perform frequent room checks, but these interventions were not documented in the care plan. The deficiencies in updating care plans for both residents highlight a lack of timely revision and inclusion of specific interventions to address their current needs. The failure to update care plans with relevant and individualized interventions poses a risk of unmet care needs and potential harm to the residents. The facility's oversight in maintaining accurate and current care plans for residents with complex medical conditions and behavioral issues is a significant concern.
Failure to Monitor and Treat Blood Glucose Levels
Penalty
Summary
The facility failed to adequately monitor and treat blood glucose levels for a resident, leading to a significant change in the resident's condition and subsequent hospitalization. The resident, who had a history of diabetes, end-stage kidney disease, and other medical conditions, experienced multiple episodes of low blood sugar over a period of several days. Despite these episodes, insulin was administered without proper documentation of blood glucose levels or physician notification, contributing to the resident's deteriorating condition. The resident's medical records revealed that insulin was given even after low blood sugar levels were recorded, and there were instances where blood glucose levels were not documented before insulin administration. On several occasions, the resident's blood sugar dropped to dangerously low levels, requiring the administration of glucagon, a medication used to treat severe hypoglycemia. The facility's staff failed to notify the physician of these repeated low blood sugar episodes, preventing timely medical intervention and assessment. The facility's care plan for the resident included specific instructions for managing diabetes, such as holding insulin if blood sugar was below a certain threshold and notifying the primary care provider if blood glucose was critically low. However, these interventions were not consistently followed, as evidenced by the lack of physician notification and continued insulin administration despite low blood sugar readings. The facility's policy on resident change in condition emphasized the importance of contacting the physician when a resident's condition changes, but this protocol was not adhered to in this case.
Failure to Maintain Cleanliness of Resident's Splint
Penalty
Summary
The facility failed to ensure proper management and monitoring of a left arm splint for a resident, resulting in the resident having a soiled hand splint that had not been laundered. The resident, who was admitted with multiple diagnoses including dementia, stroke history, and left-sided weakness, was observed with a very soiled splint that he wore at night. The resident confirmed that he did not have a second splint and was unsure if the existing one had ever been washed. The Restorative Nurse indicated that the resident was initially wearing the splint all the time, but it was later changed to nighttime use only. The nurse acknowledged that there should be an order for the splint and that nurses were responsible for assisting the resident with it. However, there was no clear responsibility for ensuring the splint was cleaned, and a policy for hand splints was not provided. The resident's care plan included the use of assistive devices and skin checks, but did not specify when the splint should be worn or cleaned.
Resident Safety Compromised During Transfer
Penalty
Summary
The facility failed to ensure the safety of a resident with severely impaired cognition and a history of combativeness, resulting in an accident that caused a laceration to the resident's left eyebrow. The resident, who had diagnoses including Dementia, Parkinson's Disease, and Alzheimer's, required assistance with all Activities of Daily Living (ADLs) and had documented behaviors of swinging and kicking at staff. On the day of the incident, the resident was involved in two separate events where they exhibited aggressive behaviors. At 11:30 AM, the resident was found on the floor and was combative when staff attempted to assist them. Later, at 1:00 PM, while being transferred from the bathroom to bed using a Sara lift, the resident hit their left eyebrow against the lift due to continued aggressive behavior. The Assistant Director of Nursing (ADON) confirmed that the resident was a one-person assist for transfers and ADL care, and the care plan did not mention the use of a Sara lift. However, the resident was assisted with the lift by just one Certified Nursing Assistant (CENA) despite having exhibited aggressive behaviors earlier that day. The ADON acknowledged the resident's behaviors and the recent changes in psychotropic medication but did not provide clarity on why the mechanical lift was used with only one staff member present, especially given the resident's recent behavioral history.
Failure to Document and Address Resident's Nutritional Needs
Penalty
Summary
The facility failed to adequately document food acceptance, provide suitable utensils, and assess, monitor, and notify the physician of a significant weight loss for a resident. Observations revealed that the resident's meals were often left untouched, and there was a lack of staff assistance during meal times. The resident struggled with using the provided utensils, which were sometimes plastic, and had difficulty consuming meals independently. Despite the resident's impaired cognition and need for setup or clean-up assistance, there was no documented effort to assist the resident during meals, leading to numerous undocumented meal consumptions. The resident experienced a significant weight loss of 5.08% over a month, with a steady decline in weight from 205.6 pounds to 187 pounds over several weeks. The nutrition progress notes indicated that the resident's appetite had declined since admission, and there was inconsistent documentation of meal and snack consumption. The dietary staff increased nutritional supplements but failed to document the provision of snacks adequately. Additionally, there was no documented notification to the physician regarding the resident's significant weight loss, and the physician was unaware of the issue during a visit.
Improper Management of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper cleaning, sanitization, and storage of respiratory equipment for residents, leading to potential cross-contamination and respiratory issues. Resident #624's CPAP machine was found dirty and not stored in its designated bag, despite physician orders requiring daily cleaning. Additionally, there was no care plan addressing the resident's CPAP or apnea needs. Resident #60's oxygen concentrator was alarming, and the oxygen tubing was on the floor, not supplying oxygen to the resident, indicating a lack of proper equipment management. Resident #2 was observed with oxygen tubing in place, but the oxygen concentrator was not turned on, leaving the resident without supplemental oxygen for an extended period. The tubing was also not dated, contrary to facility policy requiring weekly changes and labeling. The Director of Nursing confirmed the requirement for labeling and dating the tubing, highlighting a lapse in adherence to the facility's oxygen delivery system policy.
Failure to Monitor Dialysis Port Leads to Antibiotic Use
Penalty
Summary
The facility failed to assess and monitor the dialysis port for a resident, resulting in the resident starting on antibiotics. The resident, who is of advanced age, was admitted with diagnoses including end-stage renal disease, hypertensive chronic kidney disease, heart failure, and dependence on renal dialysis. Observations revealed a dressing on the resident's upper right chest where the dialysis port is located, but there was no physician order to assess and monitor the dialysis port for any changes. The resident was receiving antibiotics at the dialysis center, but was unsure of the reason. Further record review showed that the resident had been started on Vancomycin on a previous date due to drainage noted at the dialysis port site. An order to monitor the port site for signs or symptoms of infection every shift was only dated after the issue was identified. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the facility did not have a policy for assessing and monitoring dialysis port sites or shunts, and that dressings were changed every seven days or as needed, unless altered at dialysis.
Medication Cart Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and organization of medication carts, as observed during a survey. Three out of eight medication carts were found to contain crushed pills, pieces of loose paper, silver shards of foil from medication cartridges, and dust at the bottom of the drawers. This was observed during multiple inspections of the medication carts on different days, with the presence of these contaminants indicating a lack of proper cleaning and maintenance. The deficiency was noted in the medication carts located in the Patriot and Wheels units, specifically affecting the second, third, and fourth drawers of the carts. Interviews with nursing staff revealed a lack of clarity regarding the responsibility for cleaning the medication carts. Nurses RN I, LPN J, and RN K each stated that they had cleaned the carts during their previous shifts but were unsure who was responsible for regular cleaning. The Director of Nursing indicated that second shift nurses were supposed to clean the medication carts, suggesting a possible communication breakdown or lack of adherence to cleaning protocols. This lack of clear responsibility and oversight contributed to the unsanitary conditions observed in the medication carts, posing a risk of cross-contamination and potential medication errors.
Failure to Document Antibiotic Use and Indications
Penalty
Summary
The facility failed to ensure that antibiotic orders for two residents included the reason for use and that antibiotic use was tracked, leading to potential inappropriate antibiotic use. Resident #23, who had a history of stroke, epilepsy, and hypertension, was prescribed Doxycycline without a documented diagnosis or indication for its use. The physician's notes and the Infection Control Log did not provide any information on why the antibiotic was prescribed, and the resident was not listed as having an infection or receiving antibiotics in the relevant months. Similarly, Resident #79, with diagnoses including diabetes, morbid obesity, and a stage 4 sacral pressure ulcer, was prescribed Bactrim for prophylaxis without a clear reason documented in the physician's orders. Although there was a note about recurrent UTIs, this was not reflected in the orders, and the progress notes did not mention the antibiotic. The Infection Prevention and Control Nurse acknowledged the lack of documentation for the antibiotic use during an interview, stating that the electronic medical record system did not allow for adding diagnoses with the orders. The facility's Antibiotic Stewardship policy, which aims to promote appropriate antibiotic use and reduce adverse events, was not effectively implemented, as evidenced by the lack of documented indications for antibiotic orders. The report highlights the facility's failure to adhere to its own policy and the CDC's guidelines on antibiotic use, which could contribute to antibiotic resistance and other adverse effects.
Failure to Complete Comprehensive Fall Investigation and Notify Physician
Penalty
Summary
The facility failed to complete a comprehensive fall investigation and notify a physician of X-ray results for a resident, resulting in significant delays in medical treatment. The resident fell in the bathroom, hitting his face on the floor, and sustained a nasal bone fracture and a fracture on the left side of the maxilla. Despite these injuries, the facility did not send the resident to the hospital immediately, nor did they order imaging until the following day. The X-ray results, which recommended a CT scan, were not communicated to the physician for seven days, during which the resident developed subacute bilateral subdural hematomas. The facility's documentation surrounding the incident was incomplete and inconsistent. The fall event report lacked critical details, including the identity and statements of the CNA and nurses involved, the resident's statement, and the specifics of the X-ray order and results. Additionally, several sections of the fall event report were left incomplete, such as pain observation, neurological checks, and possible contributing factors. This lack of thorough documentation contributed to the delay in appropriate medical intervention. Interviews with facility staff and family members revealed discrepancies in the accounts of the fall and subsequent actions taken. The CNA involved in the incident initially left the resident alone in the bathroom, contrary to the care plan that required one assistance for toileting. The facility's failure to notify the physician promptly and the lack of clear and consistent documentation led to a significant delay in the resident receiving necessary medical evaluation and treatment for his injuries.
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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