Majestic Care Of Battle Creek
Inspection history, citations, penalties and survey trends for this long-term care facility in Battle Creek, Michigan.
- Location
- 200 E Roosevelt, Battle Creek, Michigan 49037
- CMS Provider Number
- 235023
- Inspections on file
- 33
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Majestic Care Of Battle Creek during CMS and state inspections, most recent first.
Staff failed to follow Transmission-Based Precautions for two COVID-19 positive residents on droplet precautions. One resident with severe dementia and a recent COVID-19 diagnosis had a droplet precaution sign posted, yet a social services staff member entered the room wearing only a surgical mask and did not perform hand hygiene. Another resident with COPD and moderate cognitive impairment, recently returned from the hospital with COVID-19, also had droplet precautions posted. A housekeeper entered this room wearing a gown, gloves, surgical mask, and face shield, but not the N95 mask they believed was required. The DON stated the expectation for contact with COVID-19 positive residents was use of gown, gloves, N95 mask, and face shield.
Two residents experienced changes in their skin integrity, including the development and worsening of pressure ulcers, but their care plans were not updated with new interventions to address these changes. Despite documented progression of wounds and staff acknowledgment that care plans should be revised as conditions change, the interventions remained unchanged from admission.
A resident with severe malnutrition and quadriplegia had their PEG tube dislodged, and a foley catheter was inserted in its place. The facility failed to notify the provider of this change in condition, contrary to their policy requiring notification for significant changes. Interviews revealed uncertainty among staff about whether the provider was informed.
The facility failed to provide hot beverages at a palatable temperature, as reported by several residents. A resident, who was cognitively intact, expressed dissatisfaction with cold coffee, leading to a grievance that was not addressed. The facility maintained a temperature log for hot liquids, but staff were unsure of the policy's origin. A past incident of a resident being burned by hot liquids led to a corrective plan, but the facility's policy allowed for hot beverages with interventions to minimize burn risks.
The facility failed to maintain food safety and sanitation standards, with improperly dated food items, inadequate dishwashing practices, and poor equipment maintenance. Observations included undated or improperly stored food, unclean utensils, and plumbing issues, violating FDA Food Code requirements.
The facility failed to implement an effective infection prevention and control program, particularly in managing Legionella risks in the plumbing system. Observations revealed unflushed water fixtures, including a shower and utility sink, leading to discolored water. The Water Management Program lacked active control measures, and clean supplies were stored under a wastewater line, risking contamination.
The facility failed to provide consistent and engaging activity programs, with discrepancies in activity calendars leading to resident confusion and boredom. A resident, who was cognitively intact, reported the absence of an Activity Director and frequent cancellations of activities. During a group meeting, several residents expressed similar frustrations. The Nursing Home Administrator confirmed the lack of activity staff, with CNAs filling in without proper training, leading to further inconsistencies.
A facility failed to complete required transfer and discharge documentation for a resident with multiple diagnoses, including Parkinson's and Dementia. The resident, who was cognitively intact, was hospitalized twice for UTIs and metabolic encephalopathy, but the necessary discharge/transfer notices were missing from the medical records. When requested, the facility provided an incomplete form that was not part of the original records, leading to potential mismanagement of continued care.
A facility failed to provide a resident with a written copy of the reason for transfer or discharge to the hospital in a language that was understandable, leading to potential lack of understanding. The resident, who was cognitively intact and required minimal assistance, was hospitalized twice for medical issues, but no discharge/transfer notice was found in her medical record. When requested, the facility provided an incomplete form that the resident had never seen.
A facility failed to provide a written bed hold notification in a language understandable to a resident, who was cognitively intact and had multiple diagnoses. The resident reported hospitalizations for a UTI and a fall, but there was no documentation of hospital discharge or transfer notices in the medical record. A bed hold/transfer/discharge form was provided upon request, but it lacked a date or signature and was not part of the medical record before the request. The resident stated she had never seen the form and was not given any forms during her hospitalizations.
A facility failed to timely complete and submit the PASARR form for a resident with mental illness and intellectual disabilities. The resident, who had a history of quadriplegia, schizoaffective disorder, and dementia, showed worsening behavioral symptoms. Despite scoring cognitively intact on the BIMS, no reevaluation was conducted, and the previous PASARR determination excluded a Level II assessment. Staff acknowledged the need for reassessment due to potential changes in the resident's condition.
A resident was admitted with complex medical needs, including dyskinesia and dysphasia, but the facility failed to develop baseline care plans within 48 hours. Nutritional and medication management plans were delayed, potentially leading to unmet care needs. Interviews revealed no documentation of timely care plan development.
A resident with diabetes and foot ulcers did not receive timely updates to their care plan, resulting in inadequate wound care. Despite orders for a wound vac, the facility failed to implement the treatment, citing non-compliance, which the resident disputed. The care plan lacked new interventions since the previous year, and staff did not document education provided to the resident.
A facility failed to have an emergency tracheostomy readily available for a resident with chronic respiratory failure and a tracheostomy. During care, an LPN could not immediately find the necessary equipment, which lacked an obturator. The facility's policy requires essential equipment to be easily accessible for emergencies.
A facility failed to assess a resident's ability to safely self-administer medications. The resident, with multiple diagnoses including Parkinson's and Dementia, was left alone with medications by an LPN and had a tube of normal saline at bedside for self-use. Despite being cognitively intact, a previous assessment indicated the resident could not self-administer medications, and she had requested assistance with medication administration.
A facility failed to coordinate and document hospice services for a resident, leading to inadequate care. The resident, with multiple health issues, was on hospice but lacked a clear care plan and schedule for hospice visits. Staff interviews revealed confusion and lack of awareness about hospice responsibilities, and necessary documentation was missing from the hospice binder and medical records.
The facility failed to provide grooming and bathing according to resident preferences for three residents. One resident had her hair cut due to staff neglecting to brush it, another resident's hair was not washed as per her care plan, and a third resident reported infrequent hair brushing.
The facility failed to ensure safe smoking practices for three residents, leading to a citation for accident hazards and inadequate supervision. One resident was observed rolling cigarettes in his room, another kept smoking materials in his possession without proper assessment, and a third had a strong smell of cigarette smoke in his room despite the facility's non-smoking policy. Staff interviews revealed inconsistencies in policy enforcement.
Failure to Use Appropriate PPE for Residents on Droplet Precautions
Penalty
Summary
The deficiency involves staff failure to follow the facility’s infection prevention and control program and Transmission-Based Precautions for residents on droplet precautions for COVID-19. One resident with severe vascular dementia and a recent positive COVID-19 test had a droplet precaution sign posted on the room door. Despite this, the Social Services Director entered the resident’s room wearing only a surgical mask and did not perform hand hygiene upon entry. In a subsequent interview, the Social Services Director acknowledged awareness of the droplet precautions and stated they should have slowed down and read the precaution signage on the door. Another resident with COPD, moderate cognitive impairment, and a recent positive COVID-19 test following a hospital stay also had a droplet precaution sign posted on the room door. The sign instructed that everyone must clean their hands before entering and leaving the room and ensure eyes, nose, and mouth were fully covered before entry. A housekeeper was observed in this resident’s room wearing a gown, gloves, surgical mask, and face shield. When questioned, the housekeeper stated they believed they were supposed to wear an N95 mask for this COVID-19 positive resident, acknowledged they were not wearing an N95 mask, and could not explain why. The DON later reported that the expectation for contact with COVID-19 positive residents was to wear a gown, gloves, N95 mask, and face shield.
Failure to Revise Care Plans as Residents' Conditions Changed
Penalty
Summary
The facility failed to ensure that care plans were revised as residents' care needs changed for two out of four residents reviewed. One resident was admitted with a stage III sacral pressure ulcer and subsequently developed additional pressure wounds, including unstageable and stage II ulcers on the right inner thigh and gluteal folds, as well as pressure ulcers on the left great toe and heel. Despite documented worsening of the sacral pressure ulcer over several weeks, with increasing wound size and depth, the care plan interventions remained unchanged from those implemented at admission. No new interventions were added to address the progression of the wound, and the care plan was not updated to reflect the resident's changing condition. Another resident, who did not have pressure ulcers upon admission, sustained a fall resulting in an abrasion on the back, which later developed into a stage III pressure ulcer. Although a care plan was in place identifying risk for skin breakdown, the interventions were not updated to reflect the actual development of a stage III pressure ulcer. The care plan was not revised with new interventions until a significant delay after the wound had progressed. Staff interviews confirmed that care plans should have been updated with new interventions as the residents' conditions changed, but this was not done in these cases.
Failure to Notify Provider of PEG Tube Dislodgment
Penalty
Summary
The facility failed to notify the provider of a change in condition for a resident who was admitted with severe protein-calorie malnutrition, degenerative disease of the nervous system, and quadriplegia. The resident was dependent on a PEG tube for nutrition, hydration, and medication. On December 8, 2024, the resident's PEG tube was found dislodged, and a nurse inserted a foley catheter in its place. However, the medical record did not reflect that a provider was notified of the dislodgment or that any orders were given on how to proceed with care. Interviews with facility staff revealed that the Director of Nursing was informed of the dislodged PEG tube, but there was no confirmation that a provider was notified. The facility's policy required that a provider be notified of significant changes in a resident's condition, such as the need to alter treatment. The failure to notify the provider was contrary to the facility's Change in Condition/Physician Notification policy and Enteral Feeding policy, which emphasized the importance of notifying a practitioner when a feeding tube change arises unexpectedly.
Deficiency in Providing Palatable Hot Beverages
Penalty
Summary
The facility failed to provide hot liquids at a palatable temperature to several residents, as observed during a group interview and individual resident survey. Five out of eight residents in a group interview expressed frustration with the temperature of beverages, noting that coffee and tea were consistently cold, and hot cocoa was not hot enough to dissolve properly. One resident, who was cognitively intact and had clear speech and adequate hearing, reported dissatisfaction with the cold coffee, which led to the resident's spouse bringing in coffee from outside. This resident had filed a grievance about the coffee temperature, but no changes were made by the facility. During a kitchen tour, it was found that the facility maintained a temperature log for hot liquids between 120F and 140F, but the Dietary Manager was unsure of the policy's origin. The Nursing Home Administrator and Director of Nursing were also unfamiliar with the hot liquid policy. A review of the facility's documentation revealed a past incident where a resident was burned by hot liquids, leading to a corrective plan that included evaluating residents for hot liquid risks. However, the facility's policy stated that residents should not be restricted from hot beverages, and interventions should be implemented to minimize burn risks, such as maintaining a serving temperature of not more than 180 degrees Fahrenheit and using protective measures.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. Several items in the refrigeration unit were improperly dated or lacked date markings, including hot dogs, sliced smoked ham, and strawberry sauce. This is a violation of the 2017 FDA Food Code, which requires ready-to-eat, time/temperature control for safety food to be clearly marked with a date by which they should be consumed or discarded. Additionally, a bottle of lemon juice was found unrefrigerated despite manufacturer instructions to refrigerate after opening, and several utensils and storage containers were found with food debris and were improperly cleaned. Further observations revealed that the facility's dishwashing practices were inadequate. A dietary aide was seen handling both dirty and clean dishes without washing hands or changing gloves, which is a breach of the FDA Food Code's handwashing requirements. The dish machine area was also found to have an accumulation of debris, and the physical condition of the area was deteriorating, with pitting and open holes observed near the floor. The inspection also identified issues with the facility's plumbing and equipment maintenance. The ice machine's air gap was improperly installed, creating a potential backflow risk, and the mop sink faucet was left on with a Y valve attached, which could compromise the vacuum breaker's integrity. The hot water valve was missing its handle, preventing it from being turned off. These findings indicate a failure to maintain the plumbing system in good repair, as required by the FDA Food Code.
Inadequate Water Management and Infection Control
Penalty
Summary
The facility failed to maintain an active and ongoing infection prevention and control program, specifically in managing the risk of Legionella and other opportunistic pathogens in the plumbing system. During a facility tour, it was observed that several water fixtures, including a shower fixture in a small shower room and a utility sink in the central supply room, were not being regularly flushed. The Maintenance Director (MD) admitted to not flushing certain fixtures, such as the old tub spigot in the small shower room and the utility sink, which resulted in brown and discolored water when briefly turned on. Additionally, the eyewash station in the central supply room was not regularly flushed due to the absence of a wastewater line, causing water to spill onto the floor. The facility's Water Management Program, approved in December 2023, outlined the need for an interdisciplinary water management team and specific measures to control Legionella growth, such as monitoring water stagnation and disinfection levels. However, interviews and record reviews revealed that no active and ongoing control measures or control limits were documented or in place. Furthermore, clean and sanitary nursing items were stored under a large wastewater line in the basement central supply room, posing a risk of contamination. The Maintenance Director confirmed that there were no current sampling procedures in place, and monthly meetings were held with the maintenance group but lacked in-house coordination.
Inconsistent Activity Programs and Calendars
Penalty
Summary
The facility failed to provide consistent and accurate activity calendars and meaningful, diverse, and engaging activity programs for residents. One resident, who was cognitively intact and had clear speech and adequate hearing, reported being bored due to the lack of activities and the absence of an Activity Director or Activity Aid for a month. The resident noted discrepancies between the activity calendar posted in their room and the one in the hallway, leading to confusion about scheduled activities, which were often canceled. The resident had filed multiple grievances regarding missed activities and lack of notification about changes, with no documented resolutions. During a confidential group meeting, six out of eight participants expressed similar frustrations about the lack of activities and inconsistencies in the activity calendars. The Nursing Home Administrator confirmed the absence of activity staff, with CNAs filling in without proper training. One CNA admitted to not understanding the activity calendars and substituting activities with coloring due to a lack of guidance. The CNA also reported that activities were not conducted as scheduled, with no communication to residents about changes. The facility's failure to maintain a consistent and engaging activity program was evident, with no explanation provided for the discrepancies in the activity calendars.
Failure to Complete Required Transfer and Discharge Documentation
Penalty
Summary
The facility failed to ensure that the required transfer and discharge documentation was completed for a resident, identified as Resident #20, who was reviewed for discharge. The resident had been admitted to the facility with multiple diagnoses, including Parkinson's Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain, and weakness. The resident was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 15 out of 15, and required minimal assistance with personal care. Despite these conditions, the facility did not provide the necessary hospital discharge or transfer notices for two hospitalizations related to urinary tract infections and metabolic encephalopathy. During interviews, the resident stated that she had not received any forms when she was hospitalized in March and April 2024. A review of the medical records revealed that the facility staff documented the resident's conditions, but the required discharge/transfer notices were missing. When requested, the facility provided a bed hold/transfer/discharge form with demographic information, but it lacked a date or signature and was not part of the medical record prior to the request. This oversight resulted in the omission of care plan goals from the transfer paperwork, potentially leading to ineffective or mismanaged continued care.
Failure to Provide Transfer/Discharge Notice in Understandable Language
Penalty
Summary
The facility failed to provide a written copy of the reason for transfer or discharge to the hospital in a language that was understandable to the resident, resulting in a potential lack of understanding and knowledge. This deficiency was identified for one resident, who was initially admitted to the facility with multiple diagnoses including Parkinson's Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain, and weakness. The resident was cognitively intact, as indicated by a Brief Interview of Mental Status (BIMS) score of 15 out of 15, and required minimal assistance with personal care. The resident was hospitalized on two occasions, once for a urinary tract infection (UTI) and hypoxia, and another time for metabolic encephalopathy related to a UTI. In both instances, the facility did not provide a hospital discharge/transfer notice in the resident's medical record. When requested, the facility provided a bed hold/transfer/discharge form with demographic information but without a date or signature, and it was not part of the medical record prior to the request. The resident confirmed during an interview that she had never seen the form before and was not given any forms during her hospitalizations.
Failure to Provide Bed Hold Notification in Understandable Language
Penalty
Summary
The facility failed to provide a written bed hold notification in a language understandable to Resident #20, who was reviewed for bed hold notification. Resident #20 was initially admitted to the facility and later readmitted with multiple diagnoses, including Parkinson's Disease, Diabetes Mellitus, Dementia, and others. The resident was cognitively intact, as indicated by a BIMS score of 15 out of 15, and required minimal assistance with personal care. During interviews, the resident reported hospitalizations due to a urinary tract infection and a fall, but there was no documentation of hospital discharge or transfer notices in the medical record for these hospitalizations. Upon request, the facility provided a bed hold/transfer/discharge form with the resident's demographic information, but it lacked a date or signature and was not part of the medical record before the request. The resident stated she had never seen the form and was not given any forms during her hospitalizations in March and April 2024. This lack of documentation and communication resulted in the potential for the resident to lack understanding and knowledge of the bed hold policy.
Failure to Timely Complete PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the timely completion and submission of the Preadmission Screening and Annual Resident Review (PASARR) form for a resident with mental illness and intellectual disabilities. The resident, identified as R18, was observed in a wheelchair and had a history of quadriplegia, schizoaffective disorder, bipolar type, major depressive disorder, anxiety disorder, and dementia. Despite scoring 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating cognitive intactness, the resident exhibited worsening behavioral and mood symptoms, as documented in a Behavior Management Review. The Level I PASARR completed in 2023 documented the resident's mental illness and dementia diagnosis, which led to the exclusion of a Level II PASARR. However, there was no reevaluation conducted despite significant changes in the resident's condition, such as a potential decrease or clearing of dementia, which could allow the resident to benefit from mental health services. The Social Worker and Assistant Director of Nursing acknowledged the lack of reassessment and the need to evaluate the resident's current condition, as the previous determination may no longer be applicable.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to ensure that baseline care plans were developed within 48 hours of admission for a resident, resulting in the potential for unmet care needs. The resident was admitted with multiple diagnoses, including dyskinesia, dysphasia, and other chronic conditions. Despite these complex medical needs, a nutritional care plan was not implemented until six days after admission, and a care plan addressing psychotropic, antianxiety, and antidepressant medications was not developed until 13 days after admission. This delay in care planning could have led to unmet nutritional and medication management needs. The resident's medication orders included several psychotropic and antidepressant medications, which were administered starting from the day of admission. However, the lack of a timely care plan meant that the facility did not adequately address the potential risks associated with these medications. Interviews with the Director of Nursing revealed that there was no documentation or evidence that baseline care plans were developed or provided to the resident's guardian within the required timeframe, highlighting a significant oversight in the facility's admission process.
Failure to Revise Care Plan for Resident with Wound Care Needs
Penalty
Summary
The facility failed to revise and update the care plan for a resident with multiple health issues, including diabetes mellitus with foot ulcer, peripheral vascular disease, and chronic kidney disease. The resident, who was cognitively intact, required stand-by assistance to independent personal care. Despite being under the care of a wound clinic, vascular surgeon, and primary care provider, the facility did not implement a wound vac order placed by a specialty clinic. The resident expressed concerns about the improper application of the wound vac dressing by the facility nurses, which led to the resident being sent to a wound clinic instead. Interviews with the resident and facility staff revealed discrepancies in the documentation and implementation of the wound vac orders. The resident stated that he never refused the wound vac or dressing changes, contradicting the facility's claims of non-compliance. The registered nurse responsible for the resident's wound care could not find records of the wound vac dressing changes and admitted to not documenting daily education provided to the resident. The director of nursing also confirmed that no new interventions were documented in the care plan to address the resident's wound care needs. The nurse practitioner expressed concern over the facility's failure to follow her orders for the wound vac, which she believed was necessary for the resident's healing. Despite the resident's desire to improve and return home, the facility staff cited various reasons for not implementing the treatment, such as the resident's alleged non-compliance. The care plan had not been updated with new interventions since March of the previous year, indicating a lack of timely and individualized care planning for the resident's impaired skin integrity.
Emergency Tracheostomy Equipment Not Readily Available
Penalty
Summary
The facility failed to have an emergency tracheostomy readily available for a resident, identified as R9, who required tracheostomy care. During an observation, R9 was seen resting in bed with a tracheostomy that appeared intact and clean. The resident's electronic medical record indicated a history of chronic respiratory failure with hypercapnia and a tracheostomy status since 2023. However, during a tracheostomy care session, the LPN was unable to immediately locate the emergency tracheostomy equipment, which included a sterile outer and inner cannula but lacked an obturator. The deficiency was further highlighted during an interview with the LPN, the Director of Nursing, and a Clinical Consultant, where it was confirmed that the emergency tracheostomy should be within quick reach on the wall. The facility's policy on tracheostomy care, revised earlier in the year, mandates that essential equipment such as a suction machine, suction catheters, correctly sized cannulas, and an ambu bag should be easily accessible for immediate emergency care. The absence of a complete emergency tracheostomy kit posed a potential risk for delay in emergency response.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the ability to safely self-administer medications. The resident, who was initially admitted to the facility with a readmission on 01/24/24, has diagnoses including Parkinson's Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain, and weakness. The most recent Minimum Data Set (MDS) indicated the resident was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 out of 15 and required minimal assistance with personal care. During an observation, a Licensed Practical Nurse (LPN) left the resident alone with a med cup containing 14 pills while retrieving applesauce, leaving the medications out of visual sight. Additionally, the resident was observed with a tube of normal saline at bedside, which she used as an oral rinse multiple times a day. A record review revealed an assessment from 12/16/21 stating the resident could not self-administer medications, and the resident had requested that her medications be administered to her, not self-administered.
Lack of Coordination and Documentation of Hospice Services
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in a lack of coordination of comprehensive care. The resident, who was cognitively intact and required maximum assistance with personal care, was admitted to the facility with multiple diagnoses including chronic kidney disease, bacteremia, osteomyelitis, and pressure ulcers. The resident was signed up for hospice services, but there was no calendar or schedule for hospice visits, and the CNA care plan was missing from both the hospice binder and the medical record. Interviews with facility staff revealed a lack of awareness and coordination regarding the hospice care plan and the responsibilities of hospice CNAs versus facility CNAs. The CNA and RN interviewed were not familiar with the hospice care plan, and the social worker did not engage with the clinical aspects of the care plan. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the absence of necessary documentation and coordination in the hospice binder, indicating a systemic issue in managing hospice care within the facility.
Failure to Provide Grooming and Bathing According to Resident Preferences
Penalty
Summary
The facility failed to ensure bathing and grooming were provided according to resident preferences for three residents. Resident #1, who had moderate cognitive impairment and physical impairments, reported that her hair had not been brushed for about a month by male staff members, resulting in her hair becoming tangled and eventually being cut by a staff member. The Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that male staff had received training on braiding hair but admitted that male staff felt less competent than female staff in performing hair care tasks. Resident #1 expressed that she did not want her hair cut, but it was done anyway due to the knots. Resident #2, who had severe cognitive impairment, was observed lying in bed and reported receiving bed baths but was unsure how often her hair was washed. Her medical record indicated a preference for bed baths on specific days, with hair washing included, but documentation showed that her hair was not washed on several occasions without any refusals noted. Licensed Practical Nurse (LPN) C stated that nurses should follow up and document any refusals, which was confirmed by NHA A and DON B. Resident #6, who was cognitively intact, reported that staff sometimes did not brush her hair for weeks, although she wished for daily hair brushing. She managed to avoid severe tangling by keeping her hair in a braid.
Failure to Ensure Safe Smoking Practices
Penalty
Summary
The facility failed to ensure safe smoking practices for three residents, leading to a citation for accident hazards and inadequate supervision. Resident #8 was observed rolling cigarettes in his room and admitted to keeping his lighter in his pocket, contrary to the care plan intervention that required smoking materials to be kept with facility staff. Resident #9, who had moderate cognitive impairment, reported keeping his cigarettes and lighter in his possession, with no assessment for the storage of his smoking materials and no care plan intervention for their storage. Resident #14, who was cognitively intact, was found to have a strong smell of cigarette smoke in his room on two occasions, despite the facility's non-smoking policy and the requirement for smoking materials to be kept at the front desk. The facility was unable to locate a smoking assessment for Resident #14, and the resident admitted to putting extinguished cigarette butts in the trash in his room to avoid littering the parking lot. Interviews with staff revealed inconsistencies in the enforcement of the facility's non-smoking policy. An LPN reported that no residents were allowed to keep cigarettes or lighters in their rooms, while the Nursing Home Administrator acknowledged that residents were not always compliant with the policy. The lack of proper storage and supervision of smoking materials, as well as the absence of smoking assessments for some residents, contributed to the facility's failure to provide a safe environment free from accident hazards.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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