Mission Point Nursing & Physical Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, Michigan.
- Location
- 828 East Washington Street, Greenville, Michigan 48838
- CMS Provider Number
- 235290
- Inspections on file
- 33
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehabilitation Ce during CMS and state inspections, most recent first.
A resident with diabetes and pressure ulcers did not consistently receive ordered wound dressing changes, as evidenced by multiple incomplete entries on the TAR over several months. The DON confirmed missing documentation for both completed and refused treatments, with no corresponding progress notes explaining refusals.
A resident with dementia, chronic pain, and a history of left hip dislocations did not receive care as outlined in the care plan, including use of a knee immobilizer, proper wheelchair leg support, and assistance with transfers and meals. Staff failed to follow updated care plan interventions, did not use required safety equipment during transfers, and were unaware of key care instructions, resulting in the resident being left unsupervised and improperly positioned.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
A resident with a history of pneumothorax and mild intellectual disabilities was not permitted to return to the facility after a hospital stay, despite being medically cleared and expressing a desire to return. Facility staff cited behavioral concerns and placed the resident on a 'do not admit' list without proper documentation or following required discharge procedures. Communication and documentation failures, including an incomplete bed hold form and lack of clear authorization, contributed to the resident's inability to return.
The facility failed to meet the needs of two residents, one of whom waited over an hour and a half for assistance to move from a wheelchair to bed, and another who did not receive lunch for two days due to a computer issue. These incidents highlight deficiencies in responding to residents' needs and ensuring meal service.
A resident with a history of dementia and recent antibiotic use reported loose stools for several days, raising concerns of a C. diff infection. The facility failed to promptly notify the NP or implement contact precautions. Observations showed a lack of appropriate signage and delayed communication among staff, leading to inadequate infection control measures.
A resident with cognitive impairments and a history of psychiatric issues eloped from a facility after expressing a desire to leave. Despite these statements, the resident was not considered at risk for elopement and was not equipped with a wanderguard. The resident exited the facility, triggering the door alarm, but staff did not respond promptly. A CNA eventually retrieved the resident from a nearby highway. The facility's policy emphasizes supervision and timely alarm response, which were not adequately followed in this incident.
The facility failed to maintain proper dish machine sanitization and clean food contact surfaces, increasing the risk of foodborne illness for all residents. The dish machine's chlorine sanitizer concentration was undetectable, and the hot water rinse temperature was inconsistent. Additionally, chafing pans were stored wet, and mechanical scoops were found soiled with food debris.
The facility failed to follow professional standards for medication administration for four residents, resulting in medication errors and administration outside of physician-ordered parameters. Blood pressure and heart rate assessments were either not conducted or falsified, and doses of medications were missed or inaccurately documented.
The facility failed to ensure call lights were within reach and answered promptly, and that resident needs were met in a timely manner for three residents. One resident, a quadriplegic, was found without his call light, leading to pain and anxiety. Another resident reported not being able to get out of bed due to staffing issues, and a third resident experienced significant delays in toileting assistance, causing discomfort.
A resident with dementia and hemiplegia experienced an unwitnessed fall resulting in a head injury. Despite instructions to initiate neurological checks, these were discontinued after the resident returned from the hospital with negative CT results. Miscommunication and lack of a clear policy led to inadequate monitoring, potentially compromising the resident's health and safety.
The facility failed to properly secure medications for a resident with cognitive impairment. Observations revealed that prescription Triad cream was within reach of the resident, who had not been evaluated for self-administration. Staff confirmed that treatment creams should not be stored in resident rooms without an assessment deeming the resident safe to self-administer.
The facility failed to assess and monitor an infection for a resident with a history of recurrent urinary tract infections. Despite a positive UTI being identified, the facility did not follow its Antibiotic Stewardship Program protocols, resulting in the resident going unassessed and unmonitored, with the potential for further decline and complications.
The facility failed to provide an adequate Activities Program for seven residents, resulting in boredom and feelings of anger, frustration, and depression. Due to staffing cuts, activities were reduced to two per day during the week, with no activities on the weekends, and one-on-one activities for bed-bound residents ceased. This led to increased resident behaviors, sadness, and a decline in their overall quality of life.
The facility failed to notify residents and their families about the elimination of scheduled activities and did not obtain informed consent from a resident's legal guardian before starting a new psychotropic medication. This led to a significant alteration in the care and treatment plan for the residents, particularly affecting a resident with a history of major depressive disorder and intellectual disabilities.
The facility did not review or update its Facility Assessment before eliminating the Activity Budget, Activity Assistants, and other key positions, leading to a significant reduction in meaningful activities for residents. The Nursing Home Administrator confirmed that residents and families were not informed in advance, and the Facility Assessment was not updated to reflect these changes.
The facility failed to meet the shower and hygiene needs for four residents, resulting in frustration and an unkempt appearance. One resident did not receive a shower during his stay, another had only two showers in three weeks, and two others had no documentation of showers despite their conditions requiring assistance.
The facility failed to ensure that residents received their mail on Saturdays due to staffing cuts, affecting their right to access communication. Interviews with residents and staff confirmed the issue, and a review of policies highlighted the lack of a concrete plan for weekend mail delivery.
A resident with multiple diagnoses, including severe protein-calorie malnutrition, experienced significant weight fluctuations due to the facility's use of an uncalibrated home style scale after the facility's scale broke. This led to confusion about the resident's true weight and medical needs.
The facility failed to adequately assess and monitor a resident's tube feeding placement and intake, leading to confusion about the amount of tube feeding received. The resident, with multiple diagnoses including severe protein-calorie malnutrition and dysphagia, had her feeding tube disconnected and reported requesting a new device. The facility did not document tube feeding intake or placement assessments, resulting in a significant weight loss for the resident.
The facility failed to implement behavioral interventions before administering psychotropic drugs and did not limit PRN psychotropic drugs to 14 days for a resident with multiple diagnoses. The resident exhibited behavioral symptoms, but non-pharmacological interventions were not consistently attempted. Additionally, the facility's budget cuts led to a reduction in meaningful activities, contributing to the resident's distress.
Failure to Complete and Document Ordered Wound Treatments
Penalty
Summary
The facility failed to implement ordered wound treatments for one resident who was admitted with diagnoses including diabetes, a pressure ulcer, and muscle weakness. The resident was assessed as cognitively intact, with a perfect score on the Brief Interview for Mental Status (BIMS). The resident reported that staff did not always complete her dressing changes as ordered. Review of the Treatment Administration Record (TAR) revealed multiple instances over several months where wound dressings for the resident's right lower anterior leg, right buttock, and left shin were not marked as completed by nursing staff. The Director of Nursing confirmed that there was no documentation indicating that the dressings were completed or refused on several specific dates. Additionally, refused dressing changes were not accompanied by corresponding progress notes explaining the circumstances, as required.
Failure to Implement Care Plan Interventions for Safe Transfers and Positioning
Penalty
Summary
The facility failed to implement care plan interventions and standards of care for safety with transfers, positioning, and wheelchair equipment for a resident with significant musculoskeletal and cognitive impairments. The resident, a male with dementia, chronic pain syndrome, a left hip prosthesis, intracranial injury, and muscle weakness, had a history of left hip dislocations and was care planned to have a knee immobilizer in place at all times, use left posterior hip precautions, and receive limited assist with sit-to-stand transfers to a wheelchair. The care plan also specified that the resident should eat meals in the dining room due to fall risk and required cueing for eating. Observations revealed multiple failures to follow the care plan. The resident was found eating breakfast in bed without staff assistance, struggling to cut food, and not using the dining room as care planned. The resident's wheelchair did not have a proper leg rest to support his left leg, and the walker with wheelchair footrests was left at his bedside, contrary to care plan instructions. During a transfer, a CNA did not use a gait belt and was unaware of the updated care plan interventions, including the requirement for a sit-to-stand lift for transfers. The CNA also did not know the resident was supposed to eat in the dining room and had not read the care plan that day. Interviews with staff confirmed a lack of awareness and implementation of updated care plan interventions. The physical therapist was unaware that the resident did not have a proper leg rest for his wheelchair, and the unit manager could not explain why the resident was not in the dining room for meals or why the walker was left at the bedside. Documentation indicated that staff were supposed to be informed of care plan updates through a "stop and sign" process, but the CNA had not seen or signed it until prompted during the survey.
Failure to Maintain a Safe Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Resident Not Permitted to Return After Hospitalization Due to Behavioral Concerns and Documentation Failures
Penalty
Summary
A resident with a history of pneumothorax and mild intellectual disabilities was admitted to the facility and later transferred to a local hospital due to difficulty breathing and self-injurious behavior. While hospitalized, the facility's Social Services Manager requested a psychiatric evaluation for the resident before his return. The resident was deemed medically ready for discharge by the hospital, and the therapy department recommended sub-acute rehab. However, the facility declined to permit the resident's return, citing inappropriate behaviors and placing him on a 'do not admit' list, despite the absence of documentation supporting this decision in the medical record. Communication records between the hospital and facility admissions staff revealed that the facility informed the hospital that the resident was on a 'do not admit' list and that there was no bed available, although the hospital staff indicated the resident wished to return. The facility's Business Development Manager and Admission Director both referenced the resident's behaviors as the reason for refusal, but there was confusion and lack of clarity regarding who authorized the placement on the 'do not admit' list. The Nursing Home Administrator later reported that the decision was made without her knowledge and that the facility could have met the resident's needs. Documentation related to the resident's bed hold policy was incomplete and improperly executed, with missing signatures, dates, and unclear resident consent. The resident himself reported not understanding the bed hold refusal he signed. Facility policy required that residents be permitted to return after hospitalization unless a formal discharge process, including proper notification to the resident and the State Long-Term Care Ombudsman, was followed. In this case, there was no documentation of such a process, and the resident was not allowed to return to the next available bed.
Failure to Meet Residents' Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of two residents, leading to deficiencies in care. Resident #114, an elderly female with diagnoses including muscle weakness and orthostatic hypotension, was observed with her call light on for an extended period. Despite her repeated requests for assistance to be moved from her wheelchair to her bed, she was left waiting for over an hour and a half before staff finally assisted her. This delay in response to her call light and her expressed need to lie down highlights a failure to meet her care needs promptly. Resident #112, another elderly female with diabetes mellitus and paraplegia, experienced a lapse in meal service. Despite being cognitively intact, as indicated by a perfect BIMS score, she did not receive her lunch tray for two consecutive days due to a computer issue that prevented her meal ticket from printing. This oversight was confirmed by a dietary aide, who acknowledged the problem. The failure to provide timely meals to Resident #112 demonstrates a lack of attention to her dietary needs and preferences.
Inadequate Infection Control for Resident with Suspected C. diff
Penalty
Summary
The facility failed to implement proper infection control practices for a resident who exhibited signs and symptoms of an infection. The resident, a male with a history of dementia, lack of coordination, weakness, and repeated falls, reported experiencing loose stools for several days. Despite the resident's complaints and the potential risk of Clostridium difficile (C. diff) infection due to antibiotic use, the staff did not promptly notify the Nurse Practitioner (NP) or take appropriate precautions. The NP was unaware of the resident's condition until informed during a routine check, at which point a verbal order was given to test for C. diff. The facility's failure to implement timely contact precautions and notify relevant staff members further exacerbated the situation. Observations revealed that the resident's room lacked appropriate signage for contact precautions, and staff were not informed of the need for such measures. The Unit Manager delayed notifying the Infection Control Nurse and did not ensure the collection of a stool sample promptly. Additionally, the signage used for contact precautions was incorrect, indicating the use of alcohol-based hand hygiene instead of soap and water, which is required for C. diff cases.
Elopement Incident Due to Inadequate Supervision and Alarm Response
Penalty
Summary
The facility failed to prevent an elopement incident involving a resident who was moderately cognitively impaired and had a history of dementia, bipolar disorder, and suicidal ideations. The resident, who had recently returned from a psychiatric hospital stay, expressed a desire to leave the facility and go home. Despite these statements, the resident was not considered at risk for elopement and was not equipped with a wanderguard device. On the night of the incident, the resident continued to express a desire to leave, and staff attempted to monitor her as much as possible. In the early morning hours, the resident managed to exit the facility without staff knowledge, triggering the front door alarm. A CNA observed the resident walking on a nearby road but did not initially recognize her as a resident. Upon entering the facility and hearing the alarm, the CNA informed an LPN, who confirmed the resident's identity. The LPN did not initiate a code search, believing it unnecessary since the resident's identity was known. The CNA then went outside to retrieve the resident, who was found standing on a state highway. The facility's policy on elopement and wandering residents emphasizes the need for adequate supervision and timely response to alarms. However, during the incident, staff were occupied with other duties and did not respond promptly to the door alarm. The LPN acknowledged that a wanderguard should have been used when the resident expressed a desire to leave, as its alarm is louder and more noticeable. The failure to implement appropriate interventions and respond effectively to the alarm led to the resident's elopement and placed her at risk of harm.
Failure to Maintain Dish Machine Sanitization and Clean Food Contact Surfaces
Penalty
Summary
The facility failed to maintain proper dish machine sanitization and clean food contact surfaces, leading to an increased risk of foodborne illness for all residents consuming food from the kitchen. During an inspection, it was observed that the dish machine's chlorine sanitizer concentration was undetectable, and the hot water rinse temperature was inconsistent at 143 degrees Fahrenheit. The Dietary Manager acknowledged the issue and stated that they would use the three-compartment sink for dishwashing until the dish machine could be serviced. However, even after a technician serviced the dish machine, the sanitizer concentration remained inconsistent, prompting frequent testing by the dietary staff. Additionally, four chafing pans were found stored wet in a manner that did not allow for proper air drying, and three mechanical scoops in the prep table drawer were observed to be wet and soiled with food debris. The Dietary Manager confirmed these findings and removed the items for re-washing. These observations indicate a failure to adhere to the 2017 FDA Food Code standards for equipment and utensil sanitization and storage, which require that food-contact surfaces be clean to sight and touch and stored in a self-draining position that allows air drying.
Medication Administration Failures
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for four residents, resulting in medication errors and medications being administered outside of the physician-ordered parameters. For Resident #38, there were multiple instances where blood pressure assessments were either not conducted or falsified before administering Sildenafil Citrate, which was to be held if the systolic blood pressure was less than 100. This led to the medication being administered without proper assessment or even when the blood pressure was outside the prescribed parameters. For Resident #68, Amiodarone HCl was administered despite the resident's heart rate and blood pressure being below the physician-ordered parameters on several occasions. Specifically, the medication was given when the heart rate was less than 60 and the systolic blood pressure was less than 90, contrary to the prescribed instructions. This indicates a failure to adhere to the required pre-administration assessments. Resident #1 and Resident #23 both experienced medication administration errors where doses of their prescribed medications were either missed or inaccurately documented. For Resident #1, a dose of Lacosamide was missed in the morning but documented as administered. Similarly, for Resident #23, a dose of Brivaracetam was not administered but was later documented as given, leading to discrepancies in the controlled substance count. These errors were confirmed by the Director of Nursing and highlight significant lapses in medication administration and documentation practices at the facility.
Failure to Ensure Call Lights Within Reach and Timely Assistance
Penalty
Summary
The facility failed to ensure that call lights were within reach and answered promptly, and that resident needs were met in a timely manner for three residents. Resident #18, a quadriplegic and ventilator-dependent individual, was found without his call light within reach, leading to feelings of helplessness and fear. He reported experiencing pain from being in the same position for an extended period and not being assisted to his wheelchair as requested. The call light was obscured by the privacy curtain, and staff confirmed it should have been within reach at all times. Additionally, there was no documentation to confirm that his requests to be up in his broda chair were honored, despite medical clearance for the same. Resident #18 also had a full-thickness friction skin injury on his buttocks, which was improving but still present. The lack of timely assistance and the inability to call for help exacerbated his discomfort and anxiety. The unit manager acknowledged the issue and mentioned reeducating the staff, but no corrective actions were documented before the survey exit. Resident #37, who is morbidly obese and dependent on a wheelchair, reported frustration over not being able to get out of bed when requested due to staffing issues. She mentioned that staff often told her they could not assist her because there were not enough staff available. This was corroborated by a CNA who stated that the number of CNAs on duty was insufficient to meet all residents' needs. The corporate consultant acknowledged the complaint and stated there should be enough staff, especially on weekdays, but the issue persisted. Resident #50, who has multiple sclerosis and requires substantial assistance with toileting and transfers, reported waiting up to 30 minutes for toileting assistance after pressing his call light. He recounted an incident where he had a bowel movement in his wheelchair and had to wait 30 minutes for assistance, causing him discomfort. He also mentioned another instance where he waited 30 to 40 minutes to be taken off a bedpan, which caused him pain. The delays in responding to his call light were consistent and caused significant discomfort.
Failure to Monitor Resident After Fall with Head Injury
Penalty
Summary
The facility failed to adequately monitor a resident after a fall with a head injury. Resident #27, who was admitted with diagnoses including dementia, cerebral infarction, and hemiplegia, experienced an unwitnessed fall resulting in a head injury. Despite the Post Fall Assessment form instructing staff to initiate neurological checks, these checks were discontinued after the resident returned from the hospital with negative CT results. The resident was on anticoagulant therapy, which increased the risk of complications from head injuries, yet no further neurological monitoring was conducted upon her return to the facility. Licensed Practical Nurse (LPN) J, who was on duty when the resident returned from the hospital, reported that she was informed by another nurse that neurological checks were unnecessary if the CT scan was normal. LPN J did not discuss the discontinuation of neurological checks with the Physician's Assistant (PA) C, who was supposed to evaluate the resident but did not have time. Registered Nurse (RN) D, who was not directly involved in the resident's care, stated that she would normally continue neurological checks after a head injury, even if the initial hospital tests were normal. The Director of Nursing (DON) confirmed that there was no facility policy or procedure directing staff on when to complete or discontinue neurological checks. The Corporate Consultant (CC) A reviewed the Post Fall Assessment form and acknowledged the need for staff education regarding neurological checks. The lack of a clear policy and procedure, combined with miscommunication among staff, led to the failure to adequately monitor Resident #27 after her fall, potentially compromising her health and safety. The facility's Fall Reduction Policy, which mandates assessment and completion of a Post-Fall Assessment, was not effectively implemented in this case.
Failure to Properly Secure Medications
Penalty
Summary
The facility failed to properly secure medications for Resident #435, who was moderately cognitively impaired with diagnoses including Parkinson's Disease and dementia. Observations on multiple dates revealed that prescription Triad cream was within reach of the resident on the bedside table and in the bedside drawer. The resident had not been evaluated for self-administration of medication, and the cream was required to be stored in the treatment cart. Interviews with staff confirmed that treatment creams should not be stored in resident rooms unless there was an assessment on file deeming the resident safe to self-administer. The Triad cream in Resident #435's room came from the hospital and should not have been there. This resulted in unsecured medication and the potential for cross-contamination.
Failure to Monitor and Assess Infection
Penalty
Summary
The facility failed to assess and monitor an infection for one resident who was reviewed for antibiotic use. The resident, who was cognitively intact and had a history of recurrent urinary tract infections, was admitted with diagnoses including Chronic Obstructive Pulmonary Disease and high blood pressure. Despite a positive urinary tract infection being identified through laboratory testing, the facility did not follow its own Antibiotic Stewardship Program protocols. Specifically, the resident's symptoms and vital signs were not monitored twice daily as required, and there was no documentation of these assessments in the progress notes from the time the infection was suspected until the antibiotic treatment began. During an interview, the Infection Control Preventionist confirmed that the staff should have followed the policy to obtain a urinalysis with culture and sensitivity and to monitor the resident's vital signs and symptoms twice daily. However, the necessary doctor's order could not be located in the electronic medical record, and the required monitoring and documentation were not performed. This lack of adherence to the established protocols resulted in the resident going unassessed and unmonitored, with the potential for further decline and complications from the infection.
Inadequate Activities Program Due to Staffing Cuts
Penalty
Summary
The facility failed to provide an adequate Activities Program for seven residents, resulting in boredom and feelings of anger, frustration, and depression. The facility's policy on activities, which was last reviewed on an unspecified date, stated that it would provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. However, due to staffing cuts, the activities program was significantly reduced, leading to negative impacts on the residents' well-being. One resident expressed that activities used to be available from morning until night, providing a social outlet and keeping them busy. However, with the reduction in activities, the resident felt bored, depressed, and angry. Another resident, who was described as a social butterfly, became very depressed and even attempted self-harm after the activities were reduced. The Activities Director confirmed that the department had lost five employees due to staffing cuts, leaving her as the only member of the team. As a result, activities were reduced to two per day during the week, with no activities on the weekends, and one-on-one activities for bed-bound residents ceased. Other residents also expressed their dissatisfaction with the reduced activities, stating that it made them feel unimportant and led to increased feelings of depression and boredom. Staff members, including a Registered Nurse and a Physical Therapist, observed an increase in resident behaviors and sadness since the cuts were made. The lack of activities and social interaction significantly impacted the residents' mental and emotional well-being, as they no longer had a routine or schedule to look forward to, leading to a decline in their overall quality of life.
Failure to Notify and Obtain Consent for Medication and Activity Changes
Penalty
Summary
The facility failed to notify residents, family members, and resident representatives in advance of the elimination of the majority of scheduled program activities. Additionally, the facility did not provide notification or obtain informed consent from the legal guardian of a resident before starting a new psychotropic medication, Depakote. This resulted in a significant alteration in the plan of care and treatment for all residents living at the facility, particularly affecting Resident #103, who had a history of major depressive disorder, intellectual disabilities, and other conditions. Resident #103 was cognitively intact and had a guardian in place to assist with financial and medical decisions. The resident's care plan emphasized the importance of consistent routines and participation in activities. However, the facility's decision to eliminate the activity budget and staff led to a noticeable decline in the resident's mental health. The resident's legal guardian was not informed of these changes until after they had occurred, and the resident began exhibiting increased behavioral issues, including anxiety and agitation. Furthermore, the facility started Resident #103 on Depakote without obtaining prior informed consent from the legal guardian. The medication was administered on the evening of April 2, 2024, and the guardian was only informed the following day. This action was against the facility's policy, which requires informed consent before starting new medications or making changes to the treatment plan. The failure to notify and obtain consent led to a significant alteration in the resident's care and treatment plan.
Failure to Update Facility Assessment and Notify Residents of Changes
Penalty
Summary
The facility failed to follow its Facility Assessment policy by not reviewing and revising the assessment with input from relevant department heads and resident groups before making substantial modifications. Specifically, the facility did not notify residents, families, or resident representatives in advance of the elimination of the Activity Budget, Activity Assistants, and other key positions, resulting in a significant reduction in meaningful activities for residents. The Facility Assessment had not been updated to reflect these changes since January 2024, despite the policy requiring updates whenever substantial modifications are planned or implemented. During an interview, the Nursing Home Administrator (NHA) confirmed that residents and families were not informed about the changes, and the Facility Assessment was not reviewed or updated accordingly. An emergency Resident Council meeting revealed that residents were very concerned about the elimination of activity staff and other positions. The NHA explained that the decision was not his and that he had tried to retain the staff. The Employee Roster provided to the surveyor showed only one employee remaining in the Recreation Department, indicating a significant reduction in staff and resources dedicated to resident activities.
Failure to Meet Shower and Hygiene Needs
Penalty
Summary
The facility failed to meet the shower and hygiene needs for four residents, resulting in frustration and an unkempt appearance. Resident 6, a male with multiple diagnoses including a fractured left femur and diabetes, did not receive a shower during his stay from 11/17/23 to 11/22/23. The Director of Nursing (DON) confirmed that there was no documentation of a shower being provided. Resident 8, admitted for surgical aftercare, had only two documented showers during a three-week stay, missing his scheduled weekly showers. A concern form from a family member highlighted that Resident 8 had not been showered or had his diaper changed for several days, which was corroborated by the DON and a Registered Nurse (RN). Resident 11, a female with severe medical conditions including acute pancreatitis and brain injury, had no documentation of a shower since her admission on 1/27/24. An observation on 2/5/24 revealed that her hair was greasy and uncombed, and she denied receiving any assistance with a shower. Resident 12, who required one-person assistance with showers, was observed with greasy and uncombed hair on 2/5/24. Her shower documentation showed that she missed a scheduled shower on 1/25/24 without any provided reason. The DON confirmed that Resident 12 should have received a shower on that date.
Failure to Ensure Weekend Mail Delivery
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, affecting their right to access communication. This issue was identified through interviews with three residents and staff members. Resident 7, the resident council president, expressed concern about the lack of weekend mail delivery due to staffing cuts. Resident 9 and Resident 17 also confirmed that they no longer received mail on Saturdays, with Resident 17 specifically mentioning the inconvenience of not receiving his newspaper on time. The Business Manager and Activities Director both acknowledged the problem, noting that the activities staff used to handle weekend mail delivery before being let go, and no concrete plan was in place to address the issue. A review of the facility's policy on resident rights revealed that it did not specify the requirement for mail delivery on Saturdays. However, the Medicaid Care and Coverage guidelines clearly state that residents have the right to receive mail the day it is delivered to the facility. The lack of a set plan for weekend mail delivery and the recent staffing cuts led to the deficiency, impacting the residents' ability to exercise their right to receive mail and access communication.
Inaccurate Weight Measurement
Penalty
Summary
The facility failed to accurately weigh a resident, leading to confusion about the resident's true weight and medical needs. The resident, a [AGE] year-old female with multiple diagnoses including severe protein-calorie malnutrition and dysphagia, expressed concern about her weight. Despite her concern, the facility used a home style scale, which cannot be calibrated for accuracy, to take her weight. The weights recorded showed significant fluctuations, with a notable weight loss of 12 pounds in 9 days. The resident and her family advocate were disappointed and requested to speak with the physician regarding the significant weight loss. Interviews with staff revealed that the home style scale was used after the facility's scale broke, and the staff could not recall when this occurred. The resident's weights were taken by different CNAs, and there was inconsistency in the method and location of weighing. The Registered Dietitian confirmed that the facility had been using the home style scale for an unknown period and emphasized the need for accurate scales. The facility's failure to use a reliable and calibrated scale led to inaccurate weight measurements, causing confusion about the resident's true weight and medical needs.
Failure to Monitor and Document Tube Feeding Placement and Intake
Penalty
Summary
The facility failed to adequately assess and monitor the tube feeding placement and intake for a resident, resulting in confusion about the amount of tube feeding received and the need for further intervention. The resident, a [AGE] year-old female with multiple diagnoses including traumatic brain injury, severe protein-calorie malnutrition, and dysphagia, had her feeding tube disconnected during observations. The resident reported requesting a new tube feeding device that secures the placement to reduce the risk of pullouts, and she had been sent to the emergency room due to concerns about the tube feeding placement. However, the facility did not have local services to provide the necessary care, and the resident was scheduled for follow-up care in the coming weeks. The resident's weights showed a significant decrease since admission, and there was no documentation of tube feeding intake or placement assessment in her electronic medical record. Interviews with facility staff confirmed that the resident's tube feeding intake was not being monitored, and there was no documentation of tube feeding placement assessments. The facility's dietitian acknowledged the lack of documentation and reported that an x-ray had been ordered to ensure proper placement, with plans to measure the feed once confirmed. The dietitian also educated the resident to keep the tube feeding running and implemented documentation of tube feeding intake every shift. Despite these actions, the deficiency was identified due to the initial failure to monitor and document the resident's tube feeding placement and intake properly.
Failure to Implement Behavioral Interventions and Adhere to PRN Medication Guidelines
Penalty
Summary
The facility failed to implement behavioral interventions before the initiation and administration of psychotropic drugs and ensure PRN psychotropic drugs are limited to 14 days for a resident. The resident, who had multiple diagnoses including major depressive disorder, generalized anxiety disorder, and chronic pain, exhibited behavioral symptoms such as verbal outbursts, fixation on a female staff member, and elopement risk. Despite these symptoms, the facility did not consistently attempt non-pharmacological interventions before administering psychotropic medications like Lorazepam and Depakote. The resident's care plan included interventions such as maintaining a consistent routine and providing activities to address behavioral symptoms. However, the facility did not document attempts to engage the resident in diversional activities or other non-pharmacological interventions before resorting to medication. For instance, the resident was given Lorazepam without documented non-pharmacological interventions, and the PRN order for Lorazepam did not have an end date or a documented rationale for extending it beyond 14 days. Additionally, the facility's budget for the Recreational Activity Department was eliminated, leading to a significant reduction in meaningful activities for residents. This lack of activities likely contributed to the resident's expressions of boredom and distress. The facility's failure to provide adequate non-pharmacological interventions and adhere to PRN medication guidelines resulted in the resident receiving unnecessary medications and experiencing ongoing distress.
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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