Lahser Hills Care Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Southfield, Michigan.
- Location
- 25300 Lahser Rd, Southfield, Michigan 48034
- CMS Provider Number
- 235320
- Inspections on file
- 30
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lahser Hills Care Centre during CMS and state inspections, most recent first.
A resident with paraplegia and a history of stroke developed a facility-acquired Stage 4 pressure ulcer on the right ischium. Despite a care plan for daily skin checks, documentation failed to accurately record new wounds, and wound care was not consistently documented. Wound evaluations showed the ulcer progressed from unstageable to Stage 4, with the resident attributing its development to prolonged wheelchair use. The DON could not explain documentation discrepancies, and facility protocols for pressure sore assessment and documentation were not consistently followed.
A resident experienced significant and unexplained weight fluctuations due to inaccurate weighing practices, including uncalibrated scales and inconsistent staff procedures. The facility's policy lacked guidance on referencing hospital weights, calibrating equipment, and ensuring consistent weighing methods, resulting in widespread inaccuracies in resident weight records.
The facility did not consistently follow established protocols for antibiotic use, as antibiotics were prescribed for UTIs without documented signs or symptoms and without lab confirmation. The Infection Control Preventionist confirmed that antibiotics were sometimes ordered based only on urinalysis, without culture and sensitivity testing, and could not explain how appropriate antibiotic selection was ensured in these cases.
A resident with multiple chronic conditions and intact cognition was left with a non-functioning clock in their room, despite repeated staff awareness and attempts to address the issue. The broken clock, visible from the resident's bed, was a persistent annoyance, and no maintenance ticket was recorded to resolve the problem, limiting the resident's ability to exercise choice in their environment.
Two residents were found to be using toilet safety frames with cracked and jagged armrests, creating a risk for skin tears. Staff and the DON confirmed the equipment was in disrepair and recognized the potential for injury, while one resident acknowledged the hazard. The facility's policy requires a safe and homelike environment, but the damaged equipment was not identified or addressed prior to the survey.
A resident with a diagnosis of schizophrenia was admitted without the facility notifying the local mental health authority of a significant change in condition, as required by PASARR regulations. The facility's documentation inaccurately reflected the resident's mental health status, and no updated PASARR evaluation was initiated despite ongoing psychiatric assessments and evidence of mental illness. Staff interviews confirmed that no Level II evaluation was completed or submitted.
Two residents with impaired skin conditions did not receive wound care as ordered, with dressings left unchanged for several days despite documentation indicating daily changes. One resident was found with dirty, dated bandages and could not recall care details, while another had an undated, malodorous dressing and reported missed treatments. Facility leadership acknowledged that care and documentation did not meet required standards.
Three residents received antibiotics for UTIs without meeting clinical criteria or having positive culture results. Antibiotics were started based on minimal or non-specific symptoms, such as a single low-grade fever or altered mental status, and in one case, continued even after a negative C&S result. Staff could not provide justification for the antibiotic use or explain the rationale for therapy in the absence of confirmed infection.
A resident with COPD and other comorbidities, who was dependent on continuous oxygen therapy, was left unattended for several hours with an empty portable oxygen tank and was found in respiratory distress with low oxygen saturation and blood pressure. The resident was not provided with the ordered continuous oxygen, resulting in a significant decline in condition and transfer to the hospital for a higher level of care. Facility records did not include an incident report for this event.
A resident with severe cognitive impairment was not timely evaluated for competency, and the facility failed to obtain legal guardianship or ensure proper consent for hospice services. Despite ongoing cognitive decline and the spouse's inability to act as responsible party, no alternative guardianship was pursued, and documentation of consent for hospice and related treatments was incomplete or conflicting.
Two residents developed severe pressure ulcers due to the facility's failure to prevent ulcer formation, document accurate skin assessments, and implement necessary interventions. One resident developed a Stage 4 ulcer requiring antibiotics, while another developed an unstageable ulcer. The facility's records showed missing entries for wound care treatments, and the care plan lacked additional interventions despite high-risk assessments.
The facility failed to implement enhanced barrier precautions (EBP) for two residents with wounds, leading to potential infection spread. One resident had no EBP signage or PPE, and staff provided care without gowns despite an active EBP order. Another resident with a sacral wound was not placed on EBP as per protocol. Interviews with staff, including the DON, revealed a lack of awareness and explanation for these deficiencies.
The facility failed to maintain sanitary conditions in the kitchen, with unlabeled bulk flour bins, dried food splatter on rice bins, pooling milk in the cooler, and food debris on the floors. The Dietary Manager confirmed these issues, indicating non-compliance with the 2017 FDA Food Code.
The facility failed to ensure proper administration, documentation, and storage of medications for four residents. Issues included undocumented pain medication, incorrect administration of Klonopin, medications left at the bedside, and an inhaler without a self-administration order.
The facility failed to ensure the safe and secure storage of medications across three medication carts. An RN left a medication cart unlocked and unattended, while an LPN left medications on top of the cart and walked away. Another LPN found an unidentifiable loose pill in a medication cart. The DON acknowledged these issues and confirmed that medications should not be left unattended and carts should be locked when not visible.
A resident with severe cognitive impairment was not treated with dignity and respect when a CNA ignored their requests to use the bathroom, criticized them for spilling a drink, and maneuvered them backward in a geri-chair, contrary to facility protocol.
The facility failed to complete a Level I PASARR evaluation for a resident with mental illness and intellectual disability, resulting in the potential exclusion from necessary care and services. The Social Worker Director admitted the oversight, and the Administrator confirmed the lack of a specific PASARR policy.
A resident with severe cognitive impairment and multiple diagnoses did not receive continuous oxygen therapy as prescribed. Observations showed the resident without proper oxygen supply due to issues with the oxygen concentrator and nasal cannula tubing. Staff interviews revealed inconsistent use of oxygen tanks, contrary to facility policy.
A resident reported severe pain and requested pain medication, but the MAR showed no documentation of administration since the previous night. Despite verbal confirmation from the resident, the MAR lacked proper documentation, and the DON confirmed that nurses had not recorded the administration as required by policy. Delayed documentation raised concerns about potential drug diversion.
A resident with hypertension and hypotension received Midodrine outside of physician-ordered parameters on multiple occasions, and blood pressure documentation was often missing. The DON confirmed that medications should be administered according to orders and that blood pressure should be documented, but this was not consistently done.
A resident was incorrectly administered Klonopin three times per day instead of as needed (PRN) as per the physician's order. The error was identified after family members raised concerns, and the DON confirmed the mistake. The resident's clinical record indicated severe cognitive impairment and diagnoses of failure to thrive and unspecified dementia.
The facility failed to maintain a medication error rate below five percent, resulting in a 6.25% error rate. An LPN administered Clopidogrel at the wrong time and gave an unprescribed enteric-coated Aspirin to a resident. The DON acknowledged the errors, which were identified during a medication reconciliation.
Failure to Prevent and Accurately Document Facility-Acquired Stage 4 Pressure Ulcer
Penalty
Summary
A resident with paraplegia, hypertension, and a history of stroke was admitted and later readmitted to the facility. The resident, who was cognitively intact, developed a Stage 4 pressure ulcer on the right ischium while in the facility. The care plan included daily skin checks by CNAs and reporting of abnormalities to nursing staff. However, documentation inconsistencies were noted, including a skin assessment that failed to record any new wounds despite the presence of a pressure ulcer. The treatment administration record showed the application of antifungal cream for a rash, but there was no documentation of wound care for the pressure ulcer during that period. Wound evaluations documented the progression of the pressure ulcer, initially identified as unstageable and later as Stage 4, with ongoing notes indicating the wound was stable or improving. The resident reported that prolonged use of a motorized wheelchair may have contributed to the wound's development. During interviews, the DON was unable to explain discrepancies in documentation and acknowledged that the wound could not have developed in a single day. The facility's policy required thorough assessment and documentation of pressure sores, but these protocols were not consistently followed, resulting in the resident acquiring a facility-acquired Stage 4 pressure ulcer.
Plan Of Correction
F 686 1.) Resident #80 was reassessed by the nurse manager for pressure ulcer prevention to ensure treatments were appropriate and the care plan was updated. All residents have the potential to be affected. 2.) A one-time audit was completed to ensure that all skin alterations were identified and preventative measures were in place. Licensed nurses and CENAs were re-educated on preventive skin measures, accuracy of completing skin assessments, and documentation. 3.) System change: Nurse managers will witness 5 skin assessments weekly with the nurse to ensure accuracy. Any new areas identified will be documented in the skin assessment. 4.) DON/Designee will audit 5 charts weekly x 12 weeks then monthly x 3 months to ensure appropriate preventive measures are in place, and will complete 5 random skin assessments to ensure accuracy. Any nonadherence will result in 1:1 education. All audits will be taken to the QA committee for review and further recommendations. The DON is responsible for ongoing and sustained compliance.
Failure to Ensure Accurate Resident Weights Due to Scale and Staff Errors
Penalty
Summary
The facility failed to ensure that resident weights were taken appropriately and verified as accurate according to professional standards of nutritional practice. One resident, who was thin in stature and had a history of loose dentures affecting their ability to chew, was observed with discrepancies in their recorded weights. The resident's electronic medical record showed a significant and atypical weight change of nearly 40 pounds over a two-week period, with weights fluctuating between 183.8 pounds and 144.4 pounds. The initial dietary assessment and hospital records also showed inconsistencies between the hospital discharge weight and the facility admission weight, which were not accurately reconciled at the time of admission. The facility's process for obtaining and documenting weights was inconsistent, with weights being recorded in both standing and sitting positions and by different staff members. There was no clear policy guidance on referencing hospital weights upon admission, calibrating scales, or ensuring consistency in weighing methods. The registered dietician acknowledged that scale discrepancies and staff inconsistencies contributed to the inaccurate weights, and that the issue was not identified until significant weight fluctuations were observed in multiple residents. The Director of Nursing confirmed that two of the facility's standard scales were found to be inaccurate, and that a staff member had been weighing residents incorrectly. These issues led to widespread inaccuracies in resident weight records, which were only discovered after significant fluctuations were noted. The facility's policy did not address the need for scale calibration or specific procedures for addressing weight inconsistencies, contributing to the deficiency.
Failure to Consistently Monitor and Ensure Appropriate Antibiotic Use
Penalty
Summary
The facility failed to maintain a consistent system for monitoring and ensuring appropriate antibiotic use for its residents. Review of infection surveillance records showed that antibiotics were prescribed in multiple cases without meeting established criteria, such as treating urinary tract infections (UTIs) without documented signs or symptoms of infection and without laboratory confirmation. During an interview, the Infection Control Preventionist (ICP) confirmed that McGeer's Criteria was the standard used, but acknowledged that antibiotics were sometimes prescribed based only on urinalysis (UA) results, without obtaining a culture and sensitivity (C&S) to confirm infection or guide antibiotic selection. The ICP also indicated ongoing efforts to educate nursing staff to request C&S testing, but could not explain how appropriate antibiotic selection was ensured when only a UA was performed. Facility policy required review of clinical signs, symptoms, and laboratory reports to determine the need for antibiotics, but this protocol was not consistently followed.
Plan Of Correction
1.) All Residents have the potential to be affected. 2.) A one-time audit was completed on ABT within the last 14 days to ensure they meet McGeer's criteria or have a risk versus benefits completed. The licensed nurses and providers were re-educated on McGeer's criteria. 3.) System change: Mon-Friday during the clinical meeting the ICP/Designee will review ABT to ensure they are meeting McGeer's criteria. 4.) DON/Designee will review 5 ABT weekly x 12 weeks then monthly x 3 months to ensure McGeer's criteria is met or risk versus benefit is obtained. Any non-adherence will result in 1:1 education. All audits will be brought to QA committee for review and further recommendations. The Director of Nursing is responsible for ongoing sustained compliance.
Failure to Provide Working Clock Limits Resident Choice
Penalty
Summary
A deficiency occurred when the facility failed to provide a working clock for a resident who was cognitively intact and had diagnoses including Parkinson's disease, kidney disease, and diabetes. The resident had a clear view of a clock above the door in their room, which consistently displayed the incorrect time and had a non-moving second hand. The resident reported that the clock had never worked since their admission to the room, and although batteries were replaced, the clock would only function briefly before stopping again. The resident found the broken clock to be an annoyance, especially since it was in their direct line of sight. Multiple staff members, including a LPN and a CNA, were aware of the issue and had either attempted to address it by replacing the battery or reported it verbally to maintenance. However, the problem persisted, and there was no record of a maintenance ticket in the facility's system for the clock. The facility's policy states that residents are entitled to exercise their rights and privileges to the fullest extent possible, but the ongoing issue with the clock was not resolved, impacting the resident's ability to exercise choice and self-determination regarding their environment.
Plan Of Correction
F 561 1.) Resident #67 clock was immediately replaced. All residents have the potential to be affected. 2.) A one-time audit was completed to ensure that all clocks were in working order. Nursing and Maintenance department were re-educated to ensure that clocks were working in their rooms when completing any tasks. 3.) System change: maintenance will complete weekly rounds to ensure clocks are within working order. 4.) Administrator/Designee will review 5 rooms weekly x 12 weeks then monthly x 3 months to ensure that clocks are within working order. Any non-adherence will result in 1:1 education. All audits will be submitted to the QA committee for review and further recommendations. The administrator will be responsible for ongoing sustained compliance.
Unsafe and Damaged Toilet Safety Equipment Found in Use
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents when their toilet safety equipment was found in disrepair. Observations revealed that the toilet safety frames in the bathrooms of two residents had cracked and jagged armrests, creating an opening with sharp edges where residents would typically place their hands to stand up. One resident acknowledged the risk, stating that the damaged equipment could cut someone using it. Staff, including a CNA, confirmed they had not previously noticed the damage but agreed it posed a risk for skin tears. The Director of Nursing also observed the cracked armrests and recognized the potential for injury. Both residents involved required assistance with transfers and toileting, and one was noted to be cognitively intact and their own responsible party. The most recent skin assessment for one resident showed no current skin tears or new concerns. The facility's policy requires providing a safe and homelike environment, but the presence of damaged and unsafe equipment in use did not meet this standard at the time of the survey.
Plan Of Correction
F584 1.) Resident #15 & #99 bedside commode was immediately replaced. All residents have the potential to be affected. 2.) A one-time audit was completed to ensure that all bedside commodes were in working order. Nursing, housekeeping, and maintenance departments were re-educated to ensure that bedside commodes were working in their rooms when completing any tasks. 3.) System change: housekeeping will complete weekly rounds to ensure bedside commodes are within working order. 4.) Administrator/Designee will review 5 rooms weekly x 12 weeks then monthly x 3 months to ensure that bedside commodes are within working order. Any non-adherence will result in 1:1 education. All audits will be submitted to the QA committee for review and further recommendations. The Administrator is responsible for ongoing and sustained compliance.
Failure to Notify Mental Health Authority of PASARR Change in Condition
Penalty
Summary
The facility failed to notify the local state mental health authority of a significant change in condition for a resident with a mental disorder, as required by PASARR (Preadmission Screening and Resident Review) regulations. The resident was admitted with a diagnosis of schizophrenia and had a history of psychotic episodes, as well as a documented need for antipsychotic medication. Despite this, the facility's admission Minimum Data Set (MDS) assessment inaccurately indicated that the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability, even though clinical documentation and psychiatric evaluations confirmed the presence of schizophrenia. Further review of the resident's clinical record showed that the only available PASARR documentation was a form completed at a previous facility, which noted both mental illness and dementia diagnoses. There was no evidence that the facility had updated or revised this PASARR documentation or submitted a change in condition to the local mental health agency for evaluation, despite ongoing psychiatric assessments and the resident's intact cognition as indicated by the BIMS score. Interviews with facility staff, including the Social Service Director and the Administrator, confirmed that no Level II evaluation had been completed or initiated since the resident's admission. The deficiency was identified through record review and staff interviews, which revealed a lack of appropriate review and notification regarding the resident's mental health status and PASARR requirements. The facility did not provide additional PASARR documentation or evidence of compliance with notification protocols, and staff responses indicated a misunderstanding of the need for a Level II evaluation in the presence of both mental illness and dementia diagnoses.
Plan Of Correction
F 646 1.) Resident #60, new 77/78, was completed. All residents have the potential to be affected. 2.) A one-time audit was completed on all in-house residents to ensure their PASRR screening was up to date. The SW department was re-educated on PASRR screening by the Regional Clinical Nurse Consultant. 3.) System change: the MDS department will meet with SW weekly to ensure that all new admits, significant changes, and quarterly the PASRR have been reviewed and updated as needed. 4.) The Administrator/Designee will review 5 records weekly x 12 weeks then monthly x 3 months to ensure that PASRR screenings are updated. Any non-adherence will result in 1:1 education. All audits will be submitted to the QA committee for review and further recommendations. The Administrator will be responsible for ongoing sustained compliance.
Failure to Provide Wound Care per Physician Orders and Document Accurately
Penalty
Summary
The facility failed to provide wound care according to physician's orders for two residents with non-pressure related skin conditions. One resident with dementia, type two diabetes, and varicose veins was observed with dirty and unkempt kerlex bandages on both ankles, dated six days prior, despite orders for daily dressing changes. The resident was unable to recall the reason for the bandages or the frequency of changes. Record review confirmed that staff had documented daily dressing changes, but observation indicated this was not done as ordered. Another resident with venous insufficiency, type two diabetes, and chronic pain was found with a left foot wound wrapped in undated kerlex and ace wrap, emitting a strong odor. The resident, who was cognitively intact, reported that the dressing had not been changed for several days, although daily changes with a specific solution were ordered. Staff documentation indicated treatments were completed, but physical evidence and resident interview contradicted this. Facility leadership confirmed that dressings should be dated and changed as ordered, but could not explain the discrepancies in documentation and care.
Plan Of Correction
F 684 1.) Resident #6 and #13 were re-assessed by the wound nurse and no acute issues noted. All residents have the potential to be affected. 2.) A one-time audit was completed to ensure that all dressing changes were completed as ordered. Licensed nurses were re-educated on completing dressings as ordered. 3.) System change: the nurse managers during rounds will spot check wound care dressings to ensure they are completed as ordered. 4.) The DON/Designee will observe 5 dressing changes weekly x 12 weeks then monthly x 3 months to ensure they are completed as ordered. Any nonadherence will result in 1:1 education. All audits will be brought to the QA committee for review and further recommendations. The Director of Nursing will be responsible for ongoing and sustained compliance.
Failure to Prevent Unnecessary Antibiotic Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary antibiotic therapy, as required by regulations. For one resident, antibiotics were prescribed for a urinary tract infection (UTI) based on a single low-grade fever recorded ten days prior, with no culture and sensitivity (C&S) test performed and no clear documentation of infection criteria being met. Another resident received antibiotics for a UTI despite only exhibiting altered mental status, with no C&S ordered and documentation indicating that antibiotic stewardship guidelines were not followed. In both cases, the infection control preventionist (ICP) and the director of nursing (DON) could not provide justification for the antibiotic use or explain the rationale for the chosen therapy in the absence of confirmed infection. A third resident was started on antibiotics for a UTI based on an abnormal urinalysis, with the C&S later returning negative for infection. Despite this, the resident continued to receive the full course of antibiotics. The ICP acknowledged that antibiotics should have been discontinued once the negative C&S result was received but could not explain why this did not occur. In all three cases, documentation indicated that infection criteria were not met, and antibiotics were administered without appropriate clinical justification or supporting laboratory evidence.
Plan Of Correction
F 757 1.) Resident #40, #85, and #86 were assessed by the nurse manager and no acute issues noted. 2.) A one-time audit was completed on ABT within the last 14 days to ensure they meet McGreer's criteria or have a risk versus benefits completed. The licensed nurses and providers were re-educated on McGreer's criteria. 3.) System change: Mon-Friday during the clinical meeting the ICP/Designee will review ABT to ensure they are meeting McGreer's criteria. 4.) DON/Designee will review 5 ABT weekly x 12 weeks then monthly x 3 months to ensure McGreer's criteria is met. Any non-adherence will result in 1:1 education. All audits will be brought to the QA committee for review and further recommendations. The Director of Nursing will be responsible for ongoing sustained compliance.
Failure to Provide Continuous Physician-Ordered Oxygen Therapy
Penalty
Summary
A resident with a history of chronic kidney disease, COPD, altered mental state, type II diabetes, and alcohol abuse, who was receiving hospice services and was oxygen-dependent, was not provided with continuous physician-ordered respiratory care. The resident had an order for humidified oxygen at 3L/min via nasal cannula every shift due to COPD. On the day of the incident, the resident was left unattended in the dining room for several hours with an empty portable oxygen tank and was found lethargic, slumped over a table, with a soiled brief and a dry, bloody mouth. The humidity bottle for the concentrator in the resident's room was also empty. Nursing staff discovered the resident in distress after being alerted by a nursing student. Upon assessment, the resident's oxygen saturation was found to be critically low at 80%, and blood pressure was also significantly decreased. The nurse returned the resident to their room and placed them on the concentrator at the ordered flow rate, but the oxygen saturation only improved to 86% after increasing the flow to 5L/min. The resident exhibited signs of hypoxia, including altered mental status, inability to eat or swallow, and increased confusion. The hospice nurse was contacted, and it was determined that the resident required transfer to the hospital for a higher level of care. Facility records revealed that there was no incident or accident report addressing the event involving the empty oxygen tank and resulting respiratory concerns. Interviews with staff and the physician confirmed that the resident should have been receiving continuous oxygen therapy as ordered. Facility policy on oxygen administration requires verification of physician orders and ensuring proper functioning of oxygen equipment, which was not followed in this case.
Failure to Obtain Guardianship and Proper Consent for Cognitively Impaired Resident on Hospice
Penalty
Summary
The facility failed to timely evaluate the competency of a resident with impaired cognition and did not obtain legal guardianship or ensure proper consent for hospice services. The resident, who had diagnoses including chronic kidney disease, COPD, altered mental state, type II diabetes, and alcohol abuse, was noted to have fluctuating and eventually severely impaired cognition. Despite documentation of forgetfulness, confusion, and inability to answer questions, the resident remained listed as their own responsible party, and no advanced directives or guardianship were established for an extended period. Social service notes indicated ongoing discussions with the resident's spouse about guardianship, but no action was taken to complete the process, even after the spouse expressed inability to care for the resident and requested assistance with guardianship paperwork. The facility did not pursue alternative guardianship options or seek a formal competency evaluation when the spouse failed to complete the necessary documents. Additionally, there was a lack of documentation regarding who consented to hospice services and related medical decisions, with conflicting and incomplete records about consent forms and responsible parties. Interviews with facility staff revealed uncertainty about policies and procedures for guardianship, competency evaluations, and hospice consent. The spouse reported feeling uninformed and pressured regarding hospice consent and had not been in contact with the resident for an extended period. The facility's own policy required social workers to assist with legal matters such as guardianship and to help residents determine decision-making preferences, but these actions were not completed in this case.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the formation of pressure ulcers and did not document accurate skin assessments or implement necessary interventions for two residents, R903 and R904. R903, who was admitted with encephalopathy, diabetes, and dementia, developed a Stage 4 pressure ulcer on the right ischium, which became infected and required antibiotics. The facility's records showed inconsistencies in wound care documentation, with missing entries in the Treatment Administration Record (TAR) and Medication Administration Record (MAR), indicating that prescribed treatments were not consistently administered. The Director of Nursing (DON) acknowledged the discrepancies and the need for proper documentation. R904, admitted with alcohol-induced chronic pancreatitis, depression, and calorie malnutrition, initially had no skin conditions but later developed an unstageable pressure ulcer on the coccyx. The resident's Braden Scale score indicated a high risk for pressure ulcers, yet the care plan did not include additional interventions beyond those initially set. The facility's records showed missing entries for wound care treatments, and the Wound Nurse was not informed of the resident's increased risk or nutritional concerns until after the wound developed. An order for an air loss mattress was placed but not included in the care plan. The facility's policy on pressure ulcer prevention was not followed, as residents were not adequately assessed for risk, and interventions were not introduced at the earliest possible time. The DON admitted that further attempts could have been made to prevent the development of pressure ulcers and that treatment orders should have been administered as prescribed. The lack of timely and appropriate interventions contributed to the residents acquiring severe pressure ulcers, highlighting deficiencies in the facility's wound care management and documentation practices.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds
Penalty
Summary
The facility failed to ensure appropriate infection control practices related to enhanced barrier precautions (EBP) for two residents, resulting in the potential for the spread of infection. For one resident, identified as R903, there was no EBP sign posted on the door, and the only personal protective equipment (PPE) available in the room was a box of gloves. No isolation cart or PPE supplies were observed inside or outside the room. Despite having an active physician order for EBP due to wounds, staff members, including a CNA and an LPN, were observed providing care without wearing isolation gowns. Interviews with various staff members, including the assigned nurse, unit manager, infection control nurse, and the director of nursing (DON), revealed a lack of awareness and explanation for the absence of EBP signage and PPE supplies. The DON mentioned that PPE is usually stored at the nurse station, but none was found there. The staff's failure to adhere to EBP protocols during hygiene and wound care activities was evident, as they did not use the required gowns. For another resident, identified as R904, the facility's protocol to place residents with pressure wounds on EBP was not followed. The resident had a documented fragile area on the sacrum, but there was no order for EBP when treatment was initiated. The DON confirmed that an order should have been placed, but it was not found in the resident's record. This oversight further highlights the facility's failure to implement its infection prevention and control program effectively.
Sanitary Conditions in Kitchen Not Maintained
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an initial tour. The bulk flour bin was found without a label identifying its contents, which Culinary Specialist T attributed to a recent cleaning that removed the label. Additionally, two bulk rice bins had dried food splatter on their lids and exterior surfaces. The milk cooler had pooling milk at the bottom, and various areas of the kitchen floor were observed with food debris and spills, including a large spill of a white granular substance in front of the stove, food debris behind the trash can next to the coffee maker, a pile of spilled thyme spices next to the spice rack, and food debris underneath the racks in the dry storage room. Dietary Manager S confirmed the presence of the food debris and stated that staff are supposed to mop every night but evidently had not done so adequately. These observations indicate non-compliance with several sections of the 2017 FDA Food Code, including sections 3-302.12, 4-602.13, 4-601.11, and 6-501.12. The lack of proper labeling, cleaning, and maintenance of food storage containers and kitchen surfaces could potentially affect all residents consuming food from the kitchen. The Dietary Manager acknowledged the issues but did not provide an immediate solution or explanation for the lapses in maintaining sanitary conditions.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered, documented, and stored according to professional standards of practice for four residents. For one resident, R215, the facility did not document the administration of pain medication (Oxycodone with Acetaminophen) on the Medication Administration Record (MAR) despite the resident experiencing severe pain and the medication being pulled from the supply. Additionally, a packaged medication was found on R215's tray table, indicating improper storage and handling of medications by the nursing staff. Another resident, R265, was administered Klonopin three times per day instead of as needed (PRN) as per the hospital transfer records. The error was attributed to a nurse incorrectly entering the medication order into the system. This led to the resident receiving unnecessary doses of a psychotropic medication, which concerned the resident's family members, including a licensed pharmacist. For resident R11, medications were left at the bedside, and the resident was unaware of what the medications were or how long they had been there. This was against the facility's policy that required nurses to ensure residents took their medications before signing off on the MAR. Similarly, resident R95 had a Fluticasone-Salmeterol inhaler at the bedside without a provider order for self-administration, which was also against the facility's medication administration policy.
Failure to Ensure Safe and Secure Storage of Medications
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications across three medication carts. During an observation, a Registered Nurse (RN) left a medication cart unlocked, unattended, and out of sight while administering medications to a resident. This action was in direct violation of the facility's policy, which mandates that medication carts must be closed and locked when out of the nurse's sight. Additionally, a Licensed Practical Nurse (LPN) left previously pulled medications on top of the cart and walked away, and on a separate occasion, dropped two pills on the floor and placed them back on top of the cart before walking away to administer other medications. Both actions were acknowledged by the LPN as improper and against the facility's policy, which states that no medications should be kept on top of the cart and that loose medications should be disposed of immediately. Further inspection of another medication cart revealed an unidentifiable loose pill in a blue plastic container. The LPN acknowledged the presence of the loose pill and disposed of it, in accordance with the facility's policy on medication storage. The Director of Nursing (DON) was informed of these observations and acknowledged that medications should not be left unattended and that medication carts should be locked when not visible to the nurse. The DON also confirmed that loose medication pills should not be present in the medication carts.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect. On the morning of 4/29/24, a resident (R19) with severe cognitive impairment was observed sitting in a geri-chair in the dining room. R19 announced twice that they needed to go to the bathroom, but the Certified Nursing Assistant (CNA) D told them to wait until they were done eating and did not respond the second time. After R19 finished eating, CNA D noticed that R19 had spilled their drink and had food debris on their shirt. CNA D then maneuvered R19 in the geri-chair by pulling them backward through the dining room to the shower room, which is against the facility's protocol for moving residents in geri-chairs. The resident's clinical record indicated that R19 had diagnoses of dementia, schizoaffective disorder, and major depressive disorder, with a Brief Interview for Mental Status (BIMS) assessment showing severely impaired cognition. The care plan for R19 included supervision and assistance during meals, especially near the end. The Director of Nursing (DON) confirmed that residents should always be pushed facing forward in a geri-chair and had no explanation for the observed actions. The facility document titled 'Right of Resident in Michigan Nursing Facilities' emphasizes the right of residents to a dignified existence and self-determination, which was not upheld in this instance.
Failure to Complete PASARR Evaluation
Penalty
Summary
The facility failed to ensure a Level I Preadmission Screening (PAS) and Annual Resident Review (ARR) for Mental Illness/Intellectual Disability/Related Conditions was completed accurately and sent to the local community mental health for a Level II OBRA evaluation for a resident. The resident, who was admitted and readmitted with diagnoses including schizophrenia, adjustment disorder with mixed anxiety and depressed mood, and psychotic disorder with delusions and hallucinations, had a comprehensive Minimum Data Set (MDS) assessment with the PASRR section left blank. The Level I Screening form indicated the resident had a current diagnosis of mental illness, had received treatment for mental illness, and had been prescribed antipsychotic or antidepressant medications within the last 14 days. However, there was no evidence that a Level I evaluation had been completed by the facility. During an interview, the Social Worker Director (SWD) admitted that the Level I evaluation had been overlooked. The Administrator confirmed that there was no specific policy on PASARR but stated that the facility followed Federal Regulations regarding PASARR. This oversight resulted in the potential for the resident to be excluded from receiving necessary care and services appropriate to meet their mental health and intellectual disability needs.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure continuous oxygen was provided per physician orders for a resident with severe cognitive impairment and multiple diagnoses, including dementia, schizoaffective disorder, and major depressive disorder. The resident was observed multiple times without proper oxygen supply, either due to the oxygen concentrator not being plugged in or the nasal cannula tubing being obstructed or disconnected. On one occasion, a CNA was seen transporting the resident without an oxygen tank, relying on an oxygen concentrator that required a power supply to function. Additionally, the resident was observed with the nasal cannula tubing wrapped around an oxygen tank but not attached to the resident, indicating a failure to provide the necessary continuous oxygen therapy. Interviews with staff revealed that oxygen tanks were not consistently used for residents on continuous oxygen therapy, with one LPN stating that the tanks would run out of oxygen quickly. The Director of Nursing confirmed that oxygen tanks should be used when transporting residents but had no explanation for why this protocol was not followed. The facility's policy on oxygen administration emphasized the importance of providing continuous oxygen and having a reserve oxygen tank available, but these guidelines were not adhered to in the case of the resident in question.
Failure to Accurately Document Controlled Substance Administration
Penalty
Summary
The facility failed to ensure all controlled substances were accounted for and accurately documented for a resident. On 5/1/24, the resident reported severe pain and requested pain medication before allowing any treatment. The resident had an active order for Oxycodone with Acetaminophen, but the Medication Administration Records (MAR) showed no documentation of the medication being administered since 10:07 PM on 4/30/24. Despite the resident's verbal confirmation of receiving the medication, the MAR lacked proper documentation, and the Director of Nursing (DON) confirmed that the nurses had not recorded the administration as required by policy. Further investigation revealed discrepancies in the documentation of controlled substances. The DON provided an Individual Resident's Controlled Substance Record indicating that the medication was pulled from the supply at specific times, but the MAR did not reflect this administration. The midnight nurse later added documentation to the MAR, but the process of delayed documentation raised concerns about the potential for drug diversion. The facility's policy on medication administration required immediate recording of administered medications, which was not followed in this case.
Failure to Administer Blood Pressure Medications According to Physician-Ordered Parameters
Penalty
Summary
The facility failed to administer blood pressure medications according to physician-ordered parameters for a resident with diagnoses of hypertension and hypotension. The resident received Midodrine, a medication used to treat low blood pressure, outside of the specified parameters on multiple occasions. Specifically, the resident's Medication Administration Records (MAR) showed instances where Midodrine was administered despite the resident's systolic blood pressure (SBP) being greater than 120 mmHg, which was against the physician's orders. Additionally, there were several instances where the resident's blood pressure was not documented at all, making it impossible to determine if the medication should have been administered or held. The Director of Nursing (DON) confirmed that nurses should administer medications according to physician-ordered parameters and that there should be a space to document blood pressure on the MAR. However, a review of the resident's March and April MARs revealed missing blood pressure documentation, and in some cases, the medication was held without documented justification. The facility's policy on medication administration requires obtaining and recording vital signs as necessary prior to medication administration, which was not consistently followed in this case.
Incorrect Administration of Psychotropic Medication
Penalty
Summary
The facility failed to ensure a resident received psychotropic medication as ordered. The resident, who was admitted for physical therapy and nursing care, was observed in a catatonic state. Family members, including a licensed pharmacist, expressed concerns about the administration of Klonopin three times per day, which was not noted in the hospital transfer records. The hospital records indicated that Klonopin was to be administered as needed (PRN), not on a scheduled basis. The resident's clinical record showed a diagnosis of failure to thrive and unspecified dementia without behavioral disturbances, and the resident was severely cognitively impaired. The Director of Nursing (DON) confirmed that the scheduled order for Klonopin was entered incorrectly and should have been PRN, as per the physician's order. The physician recalled that the order was intended to be PRN due to behavioral concerns when taking the resident's vitals. The facility's policy on controlled substance medication orders was reviewed, which requires accurate documentation and adherence to the prescribed orders. The discrepancy between the intended PRN order and the scheduled administration led to the deficiency in the resident's care.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in a total error rate of 6.25%. During a medication administration observation, an LPN administered Clopidogrel (Plavix) 75 mg to a resident at 9:00 AM, despite the medication being ordered for 7:00 PM. Additionally, the LPN administered Aspirin Enteric Coated (EC) 81 mg, which was not ordered by the provider. These errors were identified during a medication reconciliation of the physician's orders, which confirmed the discrepancies in the administration times and the type of medication given. The Director of Nursing (DON) was informed of the findings and acknowledged the errors. The facility's policy on medication administration requires reviewing and confirming medication orders prior to administration, verifying the medication three times, and ensuring the correct dosage and schedule. The observed actions of the LPN did not adhere to these guidelines, leading to the medication errors for the resident involved.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
