Huron Woods Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kawkawlin, Michigan.
- Location
- 1395 South Huron Road, Kawkawlin, Michigan 48631
- CMS Provider Number
- 235592
- Inspections on file
- 19
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Huron Woods Nursing Center during CMS and state inspections, most recent first.
A resident with severe dementia and physical limitations fell from a mechanical lift during transfer, resulting in a head laceration and intraventricular hemorrhage. The incident occurred when two CNAs were transferring the resident using an Invacare 450 lift and mesh sling, which allowed the resident to slip out due to instability. The facility lacked a written policy for lift use, did not provide accessible manufacturer guidance or ongoing staff training, and failed to individualize the care plan for safe transfers. The fall was not reported to the State Agency, and the investigation did not clearly identify the root cause.
A resident with multiple complex medical conditions and high dependence for daily activities experienced repeated falls from her wheelchair, resulting in injuries and hospitalization. Despite documented fall risk interventions, there were no measures for increased supervision or monitoring, and staff response to a fall was significantly delayed, contributing to the deficiency.
The facility failed to maintain safe food temperatures during breakfast service, with scrambled eggs served below the required 135 degrees Fahrenheit. The Dietary Manager confirmed that food temperatures were only checked once when removed from the oven, leading to inconsistent temperature maintenance. Additionally, an inspection revealed an unsanitary ice machine with an unknown black substance, indicating a lack of clear cleaning procedures.
The facility's infection control program was found deficient due to incomplete surveillance and tracking of infections. The Infection Control LPN confirmed that only residents receiving antimicrobial treatment were tracked, omitting those with untreated infections. This led to inadequate infection control tracking, increasing the risk of microorganism spread among residents. The facility's policy required comprehensive monitoring, but current practices did not align with these requirements.
The facility failed to respond to residents' needs in a timely and dignified manner, as reported by residents during a council meeting. Complaints included extended wait times after call lights were canceled and staff prioritizing other tasks. Residents felt neglected and dissatisfied with management's response, which advised reactivating call lights if staff did not return promptly. The Recreation Director could not provide recent council meeting minutes, as they were with the administrator.
A resident with dementia in an LTC facility was repeatedly found in soiled clothing and bedding, with a strong odor of urine and bowel movement. Despite the resident's known resistance to care, staff failed to provide consistent and adequate assistance with ADLs, resulting in undignified conditions. The care plan required oversight with dressing and bathing, but these interventions were not effectively implemented.
A resident at risk for pressure ulcers did not receive timely assessments or proper interventions, leading to improper heel positioning and a lack of skin assessments. Despite a care plan, the resident's heels were not floated, and there was a nine-day gap in skin assessments, complicating the determination of the ulcer's origin.
The facility failed to implement a comprehensive Restorative Nursing Program (RNP) for two residents, resulting in increased pain and decreased range of motion (ROM) for one resident and contracture development for another. Despite therapy recommendations, the RNP was not effectively communicated or implemented, leading to difficulties in activities of daily living (ADLs) and increased pain. Interviews with staff revealed a lack of communication and follow-through on therapy recommendations and RNP tasks.
A facility failed to provide adequate hydration for a resident, who was observed with dry, chapped lips and expressed thirst. The resident, dependent on staff for mobility and eating, did not have a beverage available in their room on multiple occasions. Despite the care plan specifying nectar-thick liquids and adaptive equipment, these interventions were not consistently implemented. Staff interviews confirmed the expectation for residents to have fresh water and assistance as needed, but no hydration policy was provided.
A resident with hypothyroidism was improperly administered Levothyroxine in the evening instead of the prescribed morning time, leading to symptoms of hypothyroidism. The medication was given alongside other medications and snacks, potentially affecting its absorption. The DON acknowledged the issue and discussed it with the responsible nurse.
Failure to Ensure Safe Mechanical Lift Transfer and Fall Prevention
Penalty
Summary
The facility failed to implement and operationalize policies and procedures to ensure safe transfer of a dependent resident using a mechanical lift, and did not ensure that planned interventions for fall prevention were in place. During a transfer using a mechanical lift, a resident with severe cognitive impairment, dementia, and significant physical limitations fell from the lift, resulting in a laceration to the forehead and an intraventricular hemorrhage. The incident occurred while two CNAs were transferring the resident from a Broda chair to bed using an Invacare 450 mechanical lift with a mesh sling. The resident slipped out of the side gap of the sling, hit their head on the metal bar of the lift, and landed on the floor. Staff interviews and demonstrations revealed that the lift and sling combination allowed for significant tipping and instability, and that the resident, who lacked core strength, was unable to support themselves during the transfer. The facility did not have a written policy or procedure for mechanical lift and sling use, relying instead on the manufacturer's guide, which was not accessible to staff. Staff training was limited to a competency check-off at hire, and there was no evidence of ongoing or refresher training. The care plan for the resident included a general intervention to follow the guide for sling type and loop attachment, but did not provide specific, individualized instructions or precautions. The investigation into the incident lacked statements from all involved staff, and the root cause of the fall was not clearly identified. The facility's documentation and staff interviews indicated confusion and inconsistency regarding how the fall occurred and what factors contributed to the resident slipping out of the sling. Following the fall, the resident experienced a significant decline in condition, including loss of ability to interact, make eye contact, or participate in activities as before. The injury was initially treated with steri-strips, but continued to bleed, requiring a pressure dressing by hospice staff. Diagnostic imaging confirmed an intracranial hemorrhage. The facility did not report the fall with severe injury to the State Agency as required. The lack of clear policies, inadequate staff training, and failure to ensure safe equipment and individualized care planning directly contributed to the resident's fall and subsequent injury.
Failure to Prevent Repeated Falls and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified when a resident experienced repeated falls from her wheelchair, resulting in injuries and hospitalization. The resident, who was cognitively intact with a BIMS score of 14, had multiple complex medical diagnoses including hemiparesis, diabetes, seizure disorder, and ischemic cardiomyopathy. She was dependent or required maximum assistance for most activities of daily living, including toileting, dressing, and personal hygiene. Despite these needs, the resident experienced three separate falls in her room over a two-month period, with the most recent incident resulting in facial injuries and a hospital transfer. Review of the resident's care plans revealed interventions such as encouraging non-skid footwear, keeping personal items within reach, using a floor mat next to the bed, and providing adaptive equipment like a wheelchair and mechanical lift. However, there were no documented interventions specifically addressing increased supervision or monitoring for this resident, despite her repeated falls. The care plans included general fall risk management strategies and environmental modifications, but did not include enhanced supervision or monitoring after the initial and subsequent falls. Interviews with the resident and her former roommate indicated that after the most recent fall, there was a significant delay in staff response, with both reporting that it took between 30 to 45 minutes for staff to arrive after the call light was activated and the roommate began yelling for help. The facility's fall management policy requires assessment, intervention, and monitoring to minimize fall risk, but the lack of timely staff response and absence of increased supervision measures contributed to the repeated falls and injuries sustained by the resident.
Deficiencies in Food Temperature Management and Ice Machine Sanitation
Penalty
Summary
The facility failed to maintain a clean and sanitary ice machine and did not ensure safe food service and holding temperatures during a breakfast meal. During an observation, it was noted that the scrambled eggs were served at temperatures below the required 135 degrees Fahrenheit. The dietary staff initially recorded the scrambled eggs at 132 degrees Fahrenheit, which was below the safe serving temperature. The Dietary Manager was informed and took corrective action by reheating the eggs to 190 degrees Fahrenheit before returning them to the steam table. However, subsequent temperature checks by another dietary staff member showed the scrambled eggs at 142.7 degrees and later at 131.0 degrees, indicating inconsistent temperature maintenance. The facility's food temperature logs revealed that scrambled eggs were recorded at 160 degrees Fahrenheit before leaving the kitchen, but there was no consistent monitoring of temperatures during service. The Dietary Manager stated that food temperatures are checked only once when removed from the oven and not during service. This practice led to discrepancies in maintaining safe food temperatures, as evidenced by the varying temperatures recorded during the breakfast service. Additionally, an inspection of the ice machine in the facility's kitchen revealed the presence of an unknown black substance on the interior ledge, which came into contact with the ice. The Dietary Manager and staff confirmed the presence of the substance and indicated that maintenance staff were responsible for cleaning the ice machine. However, there was no clear documentation or policy regarding the cleaning schedule or responsibilities, leading to unsanitary conditions in the ice machine.
Inadequate Infection Control Surveillance in LTC Facility
Penalty
Summary
The facility failed to implement a comprehensive infection control program, as evidenced by their inadequate infection surveillance and tracking system. The facility's Infection Control Resident Surveillance line listing documentation only included residents who received antimicrobial treatment, omitting those with signs or symptoms of infection who did not receive such treatment. This lack of comprehensive tracking was confirmed by the Infection Control LPN, who acknowledged that infections not treated with antimicrobials were not included in the surveillance documentation. This oversight resulted in a lack of accurate and comprehensive infection control tracking, increasing the likelihood of the spread of microorganisms and illness among the facility's 47 residents. During the review of the October 2024 Infection Control Resident Surveillance line listing, it was found that the documentation was incomplete and inconsistent. For instance, one resident was listed with multiple antimicrobial treatments for a single infection, and the onset dates were unclear. The LPN admitted that the line listing tracked the dates of antimicrobial treatment rather than the onset of infection symptoms. Additionally, the facility's monthly summary form did not provide any additional data related to the onset of infections or address antimicrobial treatments, nor did it include surveillance for potential infections that did not receive antimicrobial treatment. The facility's policy on infection prevention and control, updated in March 2024, stated that infections are monitored when a treatment plan is ordered by a healthcare practitioner. However, the policy did not ensure the inclusion of infections not requiring antimicrobial treatment in the surveillance data. The Infection Prevention Manager was responsible for the surveillance, aggregation, and analysis of data, but the current practices did not align with the policy's requirements for comprehensive monitoring and evaluation of infections and communicable diseases for all residents.
Failure to Respond to Call Lights Timely and Dignified Manner
Penalty
Summary
The facility failed to respond to residents' needs in a timely and dignified manner, as evidenced by complaints from an anonymous group of residents during a Resident Council meeting. Residents reported that staff would turn off call lights without providing immediate assistance, leading to extended wait times. One resident mentioned waiting 20 minutes after the call light was canceled, only to wait an additional 25 minutes before assistance was provided. Another resident expressed frustration at having to repeatedly engage the call light if staff did not return within 10 minutes. There were also reports of staff prioritizing other call lights and expressing reluctance to assist residents requiring more complex care, such as those needing a Hoyer lift and two staff members for assistance. The Resident Council group expressed dissatisfaction with management's response to their complaints, stating that they were advised to reactivate their call lights if staff did not return promptly. The residents felt that management's assurances of 'working on it' were insufficient, leading to feelings of neglect and insignificance. The Recreation Director was unable to provide the last six months of resident council meeting minutes, as they had been given to the administrator for uploading, and were not available before the survey concluded. This deficiency highlights a failure to honor residents' rights to a dignified existence and timely communication, as outlined in the HCAM Resident Rights booklet.
Failure to Provide Dignified ADL Care
Penalty
Summary
The facility failed to provide dignified Activities of Daily Living (ADL) care for a resident, resulting in the resident being found in soiled clothing and bedding, and a bathroom in an unsanitary condition. On multiple occasions, the resident was observed with a strong odor of urine and bowel movement emanating from their room and person. The resident was seen wearing the same soiled clothes over two days, with visible brown residue on their clothing, indicating a lack of timely assistance with personal hygiene. The resident, who has a diagnosis of dementia and severely impaired cognition, was noted to be resistant to changing clothes and accepting assistance with ADLs. Despite this, the facility staff, including CNAs and the Director of Nursing (DON), acknowledged the resident's condition but failed to ensure consistent and adequate care. The resident's care plan indicated the need for oversight with dressing in clean clothes daily and assistance with bathing, yet these interventions were not effectively implemented. Interviews with staff revealed that the resident's resistance to care was known, and strategies such as using a hairdryer to encourage showering were suggested. However, the resident continued to be found in soiled conditions, and the facility did not adequately address the resident's needs, as evidenced by the repeated observations of soiled clothing and bedding, and the persistent odor in the resident's room.
Failure in Pressure Ulcer Prevention and Assessment
Penalty
Summary
The facility failed to ensure timely assessment and implementation of interventions for pressure ulcer prevention for a resident. The resident, who was moderately cognitively impaired and dependent on staff for bed mobility and transferring, was at risk for pressure ulcer development. Despite having a care plan that included interventions such as bridging heels in bed and applying barrier cream, observations revealed that the resident's heels were not properly floated, and their foot was pressing against the footboard of the bed. The resident had a history of fragile skin and was admitted with a suspected deep tissue injury on the coccyx, which was noted to have developed during a hospital stay. However, there was a lack of consistent skin assessments, as evidenced by a nine-day gap in documentation prior to the resident's hospitalization. This gap raised concerns about the facility's ability to determine the origin of the pressure ulcer accurately. Further observations and interviews with nursing staff confirmed that the resident's heels were not appropriately positioned to prevent pressure ulcers. The wound care nurse acknowledged the improper positioning and the absence of a skin assessment during the critical period. The facility's policy required regular skin assessments to identify changes in skin condition, but this was not adhered to, contributing to the deficiency.
Failure to Implement Restorative Nursing Program Leads to Resident Decline
Penalty
Summary
The facility failed to implement a comprehensive Restorative Nursing Program (RNP) for two residents, leading to a lack of communication and implementation of planned RNP per therapy recommendations. Resident #15 experienced increased pain and decreased range of motion (ROM) in their right arm, which was not addressed by the facility's RNP. Despite being discharged from therapy with recommendations for continued exercises and ambulation, these were not effectively communicated or implemented, resulting in Resident #15's difficulty with activities of daily living (ADLs) and increased pain. Resident #30 developed a contracture and experienced a decline in ROM, which was not adequately addressed by the facility's RNP. The resident was dependent on staff for all ADLs and had impaired bilateral upper and lower extremity ROM. Despite having a care plan that included passive ROM exercises and the use of palm guards, these interventions were not consistently implemented. Staff documented completion of ROM tasks even when they were not fully performed due to the resident's pain, and therapy staff were not informed of the resident's decline in ROM or increased pain. Interviews with facility staff, including CNAs, therapists, and the Director of Nursing (DON), revealed a lack of communication and follow-through on therapy recommendations and RNP tasks. The facility's policy on restorative nursing was not effectively operationalized, leading to the residents' functional decline and increased pain. The DON acknowledged the concerns but did not provide explanations for the deficiencies in implementing the RNP.
Failure to Provide Adequate Hydration
Penalty
Summary
The facility failed to ensure the availability and provision of fluids to maintain appropriate hydration for a resident, resulting in the resident experiencing thirst and having visibly dry and chapped lips. Observations on two consecutive days revealed that the resident did not have a beverage available in their room, and their oral cavity appeared dry. The resident, who was moderately cognitively impaired and dependent on staff for mobility and eating, expressed thirst and consumed multiple cups of water when offered by staff. The resident's care plan indicated the use of adaptive equipment and specified a diet with nectar-thick liquids, but there was no evidence of consistent implementation of these interventions. Interviews with staff, including the Director of Nursing, confirmed that residents should have fresh water available and be assisted to drink if needed. However, the facility did not provide a policy or procedure related to hydration by the conclusion of the survey, indicating a lack of adherence to hydration protocols.
Improper Administration of Thyroid Medication
Penalty
Summary
The facility failed to ensure the appropriate administration of a thyroid hormone medication for a resident diagnosed with hypothyroidism, dementia, and mood disturbance. The resident was admitted on March 15, 2024, and had a physician's order for Levothyroxine Sodium, initially at 25 MCG, which was increased to 50 MCG on October 16, 2024, to be administered at 6:00 AM. However, the medication was being administered in the evening along with other medications, contrary to the prescribed time. This improper administration led to abnormal lab values and the resident experiencing symptoms of hypothyroidism, such as tiredness and constipation. Observations and interviews revealed that the resident often felt tired and constipated, preferring to stay in bed. The Director of Nursing (DON) was informed of the issue and acknowledged that the resident was receiving their thyroid medication at 8:00 PM, along with other medications like Rexult, Mirtazapine, Acetaminophen, Tamsulosin, and Atorvastatin Calcium. The DON admitted to discussing the time change with the nurse responsible. The medication administration audit report confirmed that the resident received their Levothyroxine with other medications and snacks, which could interfere with its absorption, as per the American Thyroid Association's guidelines for thyroid hormone administration.
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.
Surveyors found that multiple dependent residents did not receive consistent bathing, hair washing, shaving, or oral hygiene as required by their care plans and ADL needs. One resident with COPD, dementia, and a colostomy went at least 30 days without a documented shower or hair wash and was repeatedly observed with long chin hair despite stating she preferred it shaved. Another hospice resident’s showers and baths were provided only by hospice staff, with no evidence that facility CNAs delivered or documented any bathing during the review period, and hospice documentation was not incorporated into the facility record. A third resident with hemiplegia and major depression was observed with heavy facial hair and plaque on her teeth, reported concerns about shared razors, and had an unused personal electric shaver at bedside, while shower sheets showed no showers or bed baths in 30 days and only two documented refusals without evidence of re-approach or nurse notification.
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.
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 Provide and Document Basic ADL Care for Multiple Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document basic activities of daily living (ADL) care, including bathing, hair washing, shaving, and oral hygiene, for multiple dependent residents. One resident with COPD, dementia, colon cancer with colostomy, anxiety, and depression required substantial to maximal assistance with showering, personal care, toileting, dressing, and transfers per the MDS and care plan. This resident reported that staff only sometimes shaved her facial hair and confirmed she preferred to have her chin shaved, yet surveyors repeatedly observed long chin hairs over several days. Review of the care plan showed she needed physical assistance with personal hygiene and that staff often needed to shave whiskers on her chin. Task sheets and shower documentation revealed no recorded bath or hair wash in the last 30 days, and two shower sheets within that period documented that she was not shaved on either shower day, with no explanation for missed showers or refusals. Further interviews and record reviews showed systemic documentation and scheduling issues contributing to the lack of care. A CNA stated the resident was scheduled for showers twice weekly and that refusals were to be documented on shower sheets and escalated to the nurse, but the facility could not produce adequate shower documentation for the prior 30 days. The DON later explained that CNAs did not know how to enter PRN showers and that when the resident was moved from one bed to another months earlier, her shower task days were not updated, leading CNAs to mark “NA” and follow an outdated schedule. The DON acknowledged that the resident had been moved in June of the prior year and that staff had continued to rely on the old schedule, and also acknowledged that no one had noticed the resident was not receiving showers as ordered. Another resident on hospice services, who was dependent on staff for all ADLs, also did not receive showers or baths from facility CNAs during the review period. Hospice coordination notes showed that a hospice CNA provided showers or baths on several specific dates, but there was no documentation that facility CNAs provided any showers or baths or documented refusals during the last 30 days. The DON stated that hospice admission information and visit notes were sent to the business office and ward clerk and were expected to be scanned into the electronic record or placed in a hospice binder, but record review revealed no hospice documentation in the electronic medical record or paper chart. The hospice binder was instead sitting in someone’s email account, and the DON stated she expected facility CNAs to provide care regardless of hospice involvement. A third resident with hemiplegia, muscle disorder, cervical disc disorder, fistula, difficulty walking, and major depression was dependent for all ADLs and was observed with visible plaque buildup on her teeth and heavy facial hair on her chin and upper lip. She reported that she had asked staff to shave her facial hair but was told the same razor was used on multiple residents, leading her to refuse that method and have her husband bring in an electric razor, which remained unused on her overbed table for at least a day. A CNA confirmed that the resident had not had her facial hair shaved until that point and that she was scheduled for a bed bath that day. The care plan directed staff to shave her face as needed and to encourage her to allow shaving, and there was no care plan entry stating she did not want her facial hair shaved. Shower sheets listed her for showers/bed baths twice weekly, but documentation showed no showers or bed baths in the last 30 days, with only two dates marked as refusals and no evidence of re-approach or nurse notification. The DON stated the expectation was twice-weekly showers or bed baths and acknowledged that refusals were only documented on two dates, with no corresponding progress notes showing re-approach or nurse follow-up, aside from a single progress note where the resident refused shaving with no documented follow-up.
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.
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