Marquette County Medical Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Ishpeming, Michigan.
- Location
- 200 West Saginaw Street, Ishpeming, Michigan 49849
- CMS Provider Number
- 235321
- Inspections on file
- 15
- Latest survey
- May 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Marquette County Medical Care Facility during CMS and state inspections, most recent first.
Surveyors identified that the facility did not have emergency preparedness policies and procedures in place for the loss of natural gas, as required. This deficiency was confirmed by the Maintenance Director during record review, indicating the facility failed to address how operations would be maintained if natural gas service was interrupted.
A review of facility records and confirmation by the Maintenance Director revealed that the required monthly inspection of the hood suppression system was not conducted for one month, resulting in noncompliance with NFPA 96 standards for cooking facility fire protection.
The facility did not ensure that fire alarm signals were transmitted to the fire alarm company within a reasonable timeframe during third shift fire drills, as confirmed by the Maintenance Director during record review.
The facility did not perform specific gravity or conductance testing of generator batteries for several months, as required by NFPA standards. This lapse in maintenance protocol was confirmed by the Maintenance Director and could impact the reliability of emergency power during outages.
Surveyors found that a posted exit door from the solarium to the 600 wing was equipped with 15-second delayed egress hardware but lacked the required signage indicating, "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS," as specified by NFPA 101. The Maintenance Director confirmed the absence of this signage during the survey.
A door leading to the exterior in the 700 wing was not properly labeled with a 'NO EXIT' sign, as required, which could cause confusion during an emergency. The deficiency was confirmed by the Maintenance Director, and exit signage was not in compliance with required standards for display and illumination.
Battery-operated smoke detectors in resident rooms on two wings were found to have exceeded their 10-year lifespan and were still in use, as confirmed by the Maintenance Director during inspection and record review.
A hot water pipe was observed being supported and hanging from a sprinkler pipe in the 300 wing mechanical room, contrary to NFPA 13 requirements for sprinkler system installation. This was confirmed by the Maintenance Director during the survey.
Surveyors found that vestibule doors to the courtyard from the 500 and 600 wings did not close to a positive latch, as required for smoke resistance. This deficiency was confirmed by the Maintenance Director during the inspection.
Surveyors observed that the main entrance cross corridor smoke barrier doors did not fully close as required by LSC standards. This deficiency, confirmed by the Maintenance Director, could affect 20 occupants in the event of a fire.
Multiple hospital-grade electrical outlets in resident rooms failed inspection, and there was no documentation showing that these outlets were repaired or replaced as required. This deficiency was confirmed by the Maintenance Director.
The facility failed to develop a care plan and offer diagnostic testing or specialist consultation for a resident experiencing prolonged nausea and vomiting, resulting in significant weight loss, decline in ADLs, and multiple pressure injuries. Despite numerous progress notes documenting the resident's condition, no actions were taken to address the root cause until the day of the surveyor's interview.
The facility failed to prevent and manage pressure ulcers for two residents, leading to the development and worsening of multiple stage II pressure ulcers. Inadequate implementation of care plan interventions, unsuitable equipment, and delayed physician follow-up contributed to the deficiency.
The facility failed to update and revise care plans to prevent falls for three residents, resulting in falls with major injuries. Despite high fall risk scores and multiple incidents, appropriate interventions were not documented or implemented. The DON and RN/Rehab Coordinator acknowledged the deficiencies in care plan updates.
A resident was left unattended on the toilet with both the bathroom and room doors open, compromising their privacy and dignity. Another resident entered the room, and staff acknowledged the failure to ensure privacy and prevent wandering.
Deficient Emergency Preparedness Policy for Natural Gas Interruption
Penalty
Summary
The facility failed to develop and implement emergency preparedness policies and procedures specifically addressing the loss of natural gas to the building. During a record review, it was found that there were no established policies outlining how the facility would maintain operations in the event of an interruption to the natural gas supply. This omission was identified as a deficiency in the facility's emergency preparedness planning. The deficiency was confirmed during an interview with the Maintenance Director at the time of the record review. The lack of a policy for natural gas interruption means the facility did not meet the requirement to review and update emergency preparedness policies and procedures at least annually, as mandated. This finding could potentially affect all occupants in the event of an emergency involving the loss of natural gas.
Plan Of Correction
Element 1: Policy for Natural Gas Outage created on 06/04/2025. Element 2: All residents have the potential to be impacted by this deficiency. Best practice is to have a policy surrounding natural gas outage. Element 3: Physical plant manager and Administrator created policy and staff were educated on 06/05/2025. Element 4: Physical Plant Manager will be responsible for sustained compliance.
Failure to Complete Required Monthly Hood Suppression Inspection
Penalty
Summary
The facility failed to ensure that cooking facilities were protected in accordance with NFPA 96, as required for ventilation control and fire protection of commercial cooking operations. Specifically, a review of the Owners Hood Suppression Inspection form revealed that the facility did not conduct the required monthly inspection for December 2024. This omission was confirmed by the Maintenance Director during the surveyor's review. The deficiency was identified during a record review and interview, and it could affect all occupants in the event of a fire emergency.
Plan Of Correction
Element 1: Hood suppression inspection was not completed in December of 2024. Inspections will be completed monthly. Element 2: All staff of the food and nutrition department have the potential to be impacted. If fire spreads, all residents and staff have the potential to be impacted. Element 3: Hood suppression inspection will be completed monthly and documented as such. Element 4: Physical Plant Manager will be responsible for sustained compliance. Monthly audits will be performed with results to QAPI.
Failure to Transmit Fire Alarm Signal During Third Shift Drills
Penalty
Summary
The facility failed to conduct fire drills in accordance with requirements outlined in 19.7.1.4 through 19.7.1.7. Specifically, during a review of records for the past 12 months, it was found that fire drills conducted on the third shift (11pm-7am) did not ensure that the alarm signal was transmitted to the fire alarm company within a reasonable timeframe. This deficiency was confirmed by the Maintenance Director during the surveyor's review. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Element 1: Failure to ensure the alarm signal was transmitted to the fire alarm company within a reasonable time frame. Audible alarm will be used during all drills. Element 2: All occupants have the potential to be impacted by this deficient practice. Element 3: Physical Plant Manager instructed night shift maintenance person responsible for the drills to use audible alarm on 06/03/2025. Element 4: Physical Plant Manager will be responsible for sustained compliance. Audits will be done quarterly and brought to QAPI.
Failure to Perform Required Generator Battery Testing
Penalty
Summary
The facility failed to conduct required specific gravity or conductance testing of the generator batteries during several months, specifically in May 2024 and from July 2024 through the time of the survey. This omission was identified during a record review on May 19, 2025, and was confirmed by the Maintenance Director at the time of discovery. This deficiency indicates that the facility did not adhere to the maintenance and testing protocols for emergency power systems as outlined in NFPA 110, NFPA 99, NFPA 111, and NFPA 70. The lack of documented battery testing could affect all occupants in the event of a power failure, as the reliability of the generator or alternative power source could not be assured.
Plan Of Correction
Element 1: Facility failed to ensure generator battery was tested for specific gravity. Battery was replaced 06/04/2025 which allows for specific gravity measurement. Element 2: All occupants have the potential to be impacted in the event of power loss. Element 3: Battery was replaced 06/04/2025 which allows for specific gravity measurement. Reading was in compliance on 06/04/2025. Element 4: Physical Plant Manager will be responsible for sustained compliance. Audits will be done monthly and brought to QAPI.
Missing Required Signage on Delayed Egress Door
Penalty
Summary
A deficiency was identified when surveyors observed that the door from the solarium into the 600 wing, which serves as a posted exit, was equipped with 15-second delayed egress hardware. This door did not display the required signage stating, "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS," as mandated by NFPA 101, 7.2.1.6.1.1 (4). The absence of this signage was confirmed during the survey by the Maintenance Director at the time of discovery. The report specifies that the facility failed to ensure that doors in a required means of egress were not equipped with a latch or lock requiring the use of a tool or key from the egress side, unless the special locking arrangements for clinical needs were met according to regulatory standards. This deficiency was noted to potentially affect all occupants in the solarium in the event of a fire or emergency, as the required egress signage and compliance with special locking arrangements were not in place.
Plan Of Correction
Element 1: 600 wing exit needed a PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS sign. Signs were placed on the door on 06/03/2025. Element 2: All residents in the solarium/staff/visitors have the potential to be impacted by this deficiency. Element 3: Sign was placed on the door on 06/03/2025 stating PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. Element 4: Physical Plant Manager will be responsible for sustained compliance.
Exit Signage Not Properly Displayed and Labeled
Penalty
Summary
During an observation on May 19, 2025, it was found that door 8, which leads to the exterior of the building in the 700 wing, was not properly posted as an exit. The door could be mistaken for an exit, but lacked the required signage in accordance with section 7.10.8.3, which mandates a sign stating 'NO EXIT' for doors that are not exits. This deficiency was confirmed by the Maintenance Director at the time of discovery. The report notes that exit and directional signs were not displayed as required, nor were they continuously illuminated and served by the emergency lighting system, as specified by 19.2.10.1.
Plan Of Correction
Element 1: 700 wing door did not have NO EXIT required signage. Signs were placed on the door on 06/03/2025. Element 2: All residents on the 700 wing/staff or visitors have the potential to be impacted by this deficiency. This deficient practice could cause someone to use this door as an exit. Element 3: Signage was placed on the door on 06/3/2025 stating NO EXIT. Element 4: Physical Plant Manager will be responsible for sustained compliance.
Expired Smoke Detectors Remain in Service
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained according to an approved program in compliance with NFPA 70 and NFPA 72. During an observation and record review, it was found that battery-operated smoke detectors installed in resident rooms on the 500 and 600 wings had exceeded their 10-year lifespan, with manufacture dates of May 17, 2001, yet remained in service. This was confirmed during a physical inspection of the devices and verified by the Maintenance Director at the time of discovery. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Element 1: Resident room smoke detectors on 500/600 went beyond their 10-year life span. Unrequired room smoke detectors will be removed, as hallway smoke detectors connected to fire system are sufficient under the requirement. Element 2: There are hallway smoke detectors in these units that are connected to the building fire system. Without them, all residents, visitors, and staff of the 500/600 units would be impacted. Element 3: The battery-operated smoke detectors that are in individual resident rooms will be removed by 06/30/2025, as individual room smoke detectors are not required. Element 4: The Physical Plant Manager will be responsible for sustained compliance.
Improper Use of Sprinkler Pipe for Mechanical Support
Penalty
Summary
A deficiency was identified when, during an observation in the 300 wing mechanical room, a hot water pipe was found being supported and hanging from a sprinkler pipe. This setup was not in accordance with NFPA 13, the Standard for the Installation of Sprinkler Systems, which requires that sprinkler systems be installed as specified and not used to support other building systems. The Maintenance Director confirmed this finding at the time of discovery. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Element 1: Hot water pipe was supported and hanging from sprinkler pipe. Hot water pipe will be removed from sprinkler pipe and supported from ceiling. Element 2: All residents/visitors/staff of the 300 wing have the potential to be impacted by this deficient practice in the event of need for sprinkler use. Element 3: On 06/03/2025 the hanger was removed from the sprinkler pipe and the hot water pipe was secured directly to the ceiling. Element 4: Physical Plant Manager will be responsible for sustained compliance.
Failure of Corridor Doors to Achieve Positive Latch
Penalty
Summary
Surveyors observed that the facility failed to ensure that doors protecting corridor openings were capable of resisting the passage of smoke as required by NFPA 19.3.6.3. Specifically, during an inspection, it was found that the vestibule doors leading to the courtyard from both the 500 and 600 wings did not close to a positive latch. This deficiency was identified through direct observation between 1:29 PM and 1:52 PM on May 19, 2025. The Maintenance Director confirmed at the time of discovery that the vestibule doors did not meet the required standard for positive latching. The report does not mention any specific residents or their medical conditions in relation to this deficiency. The finding was limited to the physical condition and operation of the doors in the specified wings.
Plan Of Correction
Element 1: Doors to the courtyard from the 500 and 600 wings failed to close a positive latch. Physical plant manager contacted multiple vendors and latching hardware will be installed. Element 2: This deficient practice has the potential to impact all occupants of the 500 and 600 wings in the event of a fire. Element 3: Superiorland Electronics will install latching hardware by 07/16/2025. Element 4: Physical Plant Manager will be responsible for sustained compliance. Audits will be done monthly and brought to QAPI.
Smoke Barrier Doors Failed to Fully Close
Penalty
Summary
During an observation conducted on May 19, 2024, at approximately 1:11 PM, it was found that the main entrance cross corridor smoke barrier doors did not fully close as required by the Life Safety Code (LSC). The doors are intended to be 1-3/4-inch thick solid bonded wood-core or of equivalent fire-resistant construction, and must be self-closing or automatic-closing to maintain the integrity of the smoke barrier. The failure of these doors to completely close was confirmed at the time of discovery by the Maintenance Director. This deficiency could potentially affect 20 occupants in the event of a fire, as the doors did not meet the required standards for smoke barrier subdivision.
Plan Of Correction
Element 1: Doors in the entry hallway failed to completely close. Doors and air flow were adjusted for complete closure. Element 2: This deficient practice has the potential to impact the 20 staff near those doors in the event of a fire. Element 3: On 06/03/2025, Automated Comfort Controls were at the facility readjusted the air flow to allow for complete closure of fire doors. Element 4: Physical Plant Manager will be responsible for sustained compliance. Audits will be done weekly x 8 weeks then monthly and brought to QAPI.
Failure to Test and Repair Hospital-Grade Electrical Receptacles
Penalty
Summary
The facility failed to ensure that hospital-grade electrical receptacles at patient bed locations and areas where deep sedation or general anesthesia is administered were tested after initial installation, replacement, or servicing, as required by NFPA 99. During a record review, it was found that multiple outlets in resident rooms throughout the building failed inspection in 2024, and there was no documentation or evidence provided to show that these outlets were repaired or replaced. This deficiency was confirmed by the Maintenance Director at the time of discovery. No information was provided regarding the specific medical history or condition of the residents affected at the time of the deficiency.
Plan Of Correction
Element 1: Multiple outlets in resident rooms failed inspection and documentation did not indicate repair or replacement. Documentation now includes date and type of corrective action. Element 2: This deficient practice has the potential to impact the 30 residents near those outlets in the event of a fire. Element 3: Physical Plant Manager instructed maintenance personnel to document the date and type of corrective action on 06/03/2025. Element 4: Physical Plant Manager will be responsible for sustained compliance. Audits will be done monthly and brought to QAPI.
Failure to Address Prolonged Nausea and Vomiting
Penalty
Summary
The facility failed to develop a care plan and offer or recommend diagnostic testing or consultation with a Gastroenterologist or Physician Specialist to determine the source of prolonged nausea and vomiting for one resident. This deficiency resulted in the resident sustaining a 27.3% weight loss over six months, a decline in activities of daily living (ADL), a significant change of condition, and the development of multiple pressure injuries. The resident was admitted to the facility and was documented as requiring staff assistance for ADLs, with a BIMS score indicating cognitive intactness. Despite numerous progress notes documenting the resident's nausea and vomiting, the care plan did not address these issues, nor was there any indication that the weight loss was desirable by the resident. The medical record revealed significant weight loss and numerous instances of nausea and vomiting documented over several months. Despite these ongoing issues, there was no documentation of any discussion with the resident regarding diagnostic testing or consultation with a specialist. The physician's visit notes from several months did not include plans to address the nausea or offer diagnostic testing. The resident's care plans did not contain interventions for nausea and vomiting, and the medical record did not reveal any discussion with the resident about consulting a specialist or obtaining diagnostic testing. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) Supervisor confirmed awareness of the resident's recurrent nausea and vomiting but revealed that diagnostic testing or specialist consultation had not been discussed with the resident. The resident expressed frustration with the prolonged nausea and vomiting and indicated that the physician had only recently offered to conduct testing. The physician admitted to not knowing the cause of the nausea and vomiting and acknowledged that the resident had declined further testing or consultations only on the day of the interview. The facility policy on significant change notification was not followed, as the Medical Director was not made aware of the prolonged nausea and vomiting experienced by the resident.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to implement and maintain interventions to prevent the development and progression of pressure ulcers for two residents. Resident #62 was admitted with no pressure ulcers but developed multiple stage II pressure ulcers during their stay. Despite being at risk for pressure ulcers, the resident's care plan interventions were not effectively implemented. Observations revealed that the resident's wheelchair was not suitable, and the Roho cushion was deflated, contributing to the development of pressure ulcers. Interviews with the occupational and physical therapists confirmed that the wheelchair was not a good fit and that the cushion was not properly inflated. The resident's progress notes indicated the development and worsening of pressure ulcers, but no changes were made to the care plan interventions to address these issues. Resident #113 was admitted with existing pressure ulcers, which worsened during their stay. The resident's wounds showed signs of infection and progression to a stage IV ulcer. Despite these changes, there was no timely physician follow-up or wound care consultation. The wound care treatment coordinator made multiple attempts to contact the physician for a wound care consultation, but there was no response. The delay in obtaining a wound care consultation resulted in a 14-day lapse from the initial request to the actual consultation. The facility's policies on significant change notification and skin integrity program were not followed, leading to inadequate management of the resident's worsening wounds. The deficiency in pressure ulcer care for both residents highlights a failure in the facility's implementation and maintenance of appropriate interventions. The lack of timely physician follow-up and inadequate communication within the interdisciplinary team contributed to the worsening of the residents' conditions. The facility did not adhere to its policies, resulting in delayed treatment and progression of pressure ulcers for the affected residents.
Failure to Update Care Plans for Fall Prevention
Penalty
Summary
The facility failed to implement, update, and revise comprehensive care plans to prevent falls for three residents, resulting in falls with major injuries. Resident #26, who had a history of falls and a high fall risk score, fell and sustained a left femur fracture. Despite her high risk, the facility did not initiate or document appropriate fall interventions upon her return from the hospital. The Director of Nursing (DON) acknowledged that the facility's fall watch program was not properly implemented for this resident. Resident #9, who had moderate cognitive impairment and multiple diagnoses, fell and sustained a skin tear. The care plan for this resident was not updated to include interventions to prevent further falls. The DON confirmed that the care plan was not revised after the fall, and the RN/Rehab Coordinator stated that falls caused by a urinary tract infection were not typically updated in the care plan. Resident #29, who had intact cognition and multiple diagnoses, experienced multiple falls without any interventions being added to the care plan. The resident fell on three separate occasions, and each time, the care plan was not updated to include fall prevention measures. The DON and RN/Rehab Coordinator both acknowledged that changes were noted in the resident's records but were not reflected in the care plan. The facility's policy on fall risk management was not followed, leading to inadequate monitoring and prevention of falls for these residents.
Failure to Provide Dignified ADL Care
Penalty
Summary
The facility failed to provide activities of daily living (ADL) care in a dignified manner to a resident (R17). On 6/3/24 at 3:10 PM, a CNA was observed assisting R17 to the bathroom. Subsequently, R17 was left unattended on the toilet with both the bathroom door and the room door open. This lack of privacy was further compromised when another resident (R57) entered R17's room in a wheelchair. CNA G redirected R57 out of the room but acknowledged that the door should have been partially closed to prevent such incidents, especially since R17 is a fall risk. CNA D admitted to leaving R17 unattended with the doors open because he needed to retrieve a brief and did not seek assistance. He acknowledged that R17 did not have privacy and that he should have handled the situation differently. The Nursing Home Administrator confirmed that staff are expected to close doors to provide privacy and prevent wandering residents from entering rooms. The failure to close the doors resulted in a breach of R17's dignity and privacy while using the bathroom.
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.
