Mission Point Nursing & Physical Rehabilitation Of
Inspection history, citations, penalties and survey trends for this long-term care facility in Big Rapids, Michigan.
- Location
- 725 West Fuller, Big Rapids, Michigan 49307
- CMS Provider Number
- 235312
- Inspections on file
- 24
- Latest survey
- July 18, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehabilitation Of during CMS and state inspections, most recent first.
Three residents experienced deficiencies in medical record documentation, including missing consent forms for certain medications, discharge summaries that were copied from admission orders rather than reflecting the actual stay, and incomplete transfer documentation lacking communication of key information and bed hold policy details.
A resident with severe cognitive impairment and multiple medical conditions experienced several changes in condition and treatment, including new medications, illness, and interventions, without documented notification to the responsible party. The guardian reported not being consistently informed, and EMR review confirmed a lack of documentation regarding notification for significant events and care changes.
Two residents did not have their care plans properly reviewed, revised, or implemented. One resident with muscular dystrophy and dysphagia did not have a required floor mat in place after a fall and was observed eating unsupervised in bed despite care plan instructions. Another resident with traumatic brain dysfunction lacked an updated communication plan, had no communication board available, and there was no documentation of required monitoring.
Two residents did not receive medications according to professional standards: one with dysphagia had medications left at bedside without observation despite not being cleared for self-administration, and another with COPD was not instructed to rinse and spit after using an inhaler as ordered. Facility staff did not follow established medication administration policies.
The facility did not ensure insulin was administered according to provider orders and failed to monitor and report abnormal blood sugar results for three residents with diabetes. Insulin was given outside of ordered parameters without documented rationale, high blood sugar readings were not reported to the provider as required, and daily blood sugar checks were not consistently performed or documented, contrary to facility policy.
A resident with Obstructive Sleep Apnea did not receive proper care for their CPAP device, as the mask was not stored in a bag and the filter was moderately soiled on multiple observations. The resident reported that staff had not cleaned the device in a long time, and records did not consistently reflect required maintenance, despite facility policy mandating daily cleaning and proper storage.
The facility did not ensure proper dispensing and documentation of controlled medications for three residents. Controlled substances were dispensed without corresponding documentation of administration, and in some cases, medications were dispensed without an active order or without proper recordkeeping in the MAR or electronic medical record. These actions were not in accordance with facility policy requiring accurate accountability for controlled substances.
Two residents received incorrect medication dosages when an LPN administered double the prescribed amount of vitamin D3 to one resident, and two nurses gave twice the ordered dose of morphine sulfate to another resident. These errors resulted in a medication error rate of 6.66%, exceeding the acceptable threshold, and occurred despite facility policy requiring verification of the correct dosage and review of the MAR.
Surveyors found that a discus inhaler and a nasal spray were not labeled with a resident's name, even though their boxes were labeled. Nursing staff confirmed that medications should be labeled to ensure correct administration and identification if separated from their packaging.
The facility did not complete annual performance reviews for nurse aides or provide regular in-service education based on those reviews. Review of staff files showed that at least two CNAs had not received required evaluations or consistent ongoing training, and the administrator confirmed that performance reviews had been put on hold by HR, resulting in non-compliance with regulatory requirements.
Surveyors identified that two residents' rooms and adjacent hallways had persistent urine odors due to inadequate cleaning and improper management of incontinence and urinal disposal. Staff and resident council feedback confirmed that toilets and urinals were not consistently cleaned, resulting in unclean and uncomfortable conditions.
A resident with dementia and weakness was not provided with an appropriately sized drinking cup, despite repeated requests from her family and clear instructions in her care plan. The facility failed to consistently offer a smaller, manageable cup, raising concerns about the resident's hydration.
A resident reported her cell phone and money missing shortly after admission, but the facility failed to investigate or report the allegations to the state survey agency. Despite the resident's reports to staff and administration, no concern forms or incident reports were filed, and the Nursing Home Administrator was unaware of the situation until informed by a surveyor. The facility did not comply with its policy requiring immediate reporting of such allegations.
A resident with multiple sclerosis and cognitive deficits did not receive adequate oral care or assistance with mobility as per their care plan. The resident's guardian reported infrequent oral care and lack of use of an oral moisturizer gel. Observations confirmed the resident's mouth was often dry with secretions. CNAs admitted to providing oral care less frequently than required, and the resident was not regularly assisted into his wheelchair, contrary to his care plan.
The facility failed to provide meaningful activities for two residents with dementia, as observed during a survey. One resident was observed sleeping during the day, with no activities documented in the past 30 days, despite a care plan goal for one-on-one activities. Another resident also lacked documented activities, with a family member expressing concern about the absence of engagement when they were not present.
A resident with multiple sclerosis and contractures was not provided with necessary hand splints as required. Observations revealed the resident without splints, and staff were unaware of the splint schedule. Documentation showed inconsistencies, and no physician orders for splints were found, leading to a deficiency in care.
The facility failed to manage medications properly, with expired medications found in the Northwest Medication Cart and the Southwest Medication Cart left unlocked and unattended. Staff interviews confirmed that medication carts should be locked when not in use, but this protocol was not consistently followed.
The facility failed to protect the confidentiality of medical records for two residents, as their e-MARs were left open and unattended on a medication cart, visible to passersby. Staff interviews revealed a lack of adherence to the facility's policy requiring screens to be closed when not attended, in compliance with HIPAA regulations.
The facility failed to provide collaborative hospice care for two residents. Staff were unaware of hospice schedules and lacked documentation of services provided. One resident, with Parkinson's and failure to thrive, was in distress and preferred hospice for showers, which were not documented. Another resident, with dementia and weight loss, had no recent hospice visits documented, and her sleep patterns were not communicated to hospice.
The facility failed to clean a glucometer per manufacturer's instructions, risking infection spread. Two residents had their blood glucose levels checked with a glucometer cleaned inadequately using 70% isopropyl alcohol prep pads instead of EPA-approved disinfecting wipes. Staff interviews revealed confusion about proper cleaning protocols, with some using alcohol pads despite guidelines requiring specific germicidal wipes.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, resulting in deficiencies related to documentation and safeguarding of resident-identifiable information. For one resident with multiple psychiatric diagnoses, the medical record did not contain documentation that the resident was informed in advance about the risks, benefits, and alternatives for certain prescribed medications, specifically Benztropine Mesylate and Bupropion, prior to administration. Although the facility had obtained consent for other antipsychotic medications, there was no evidence of consent for these two medications in the resident's record. Another resident, admitted following elective spinal surgery, had discharge documentation that included a summary of their stay. However, the nursing summary was found to be a direct copy-and-paste from a physician order regarding the reason for admission, rather than a true summary of the resident's stay at the facility. The nurse manager confirmed this practice, stating it was standard procedure to copy the admission order into the discharge summary, rather than providing an individualized account of the resident's progress and care during their stay. A third resident, who was cognitively intact and admitted with quadriplegia, was transferred to the hospital following a change in condition. The medical record lacked documentation that pertinent information about the resident's condition was communicated to the receiving hospital, and there was no record that the resident was informed about the facility's bed hold policy. Additionally, the required Interact transfer form was not completed or entered into the medical record for this transfer event. A late entry was made in the progress notes to indicate the hospital was notified, but it still did not include information regarding the bed hold policy.
Failure to Notify Responsible Party of Resident Condition Changes
Penalty
Summary
The facility failed to notify the responsible party of changes in condition and treatment for one resident who was admitted with traumatic brain dysfunction, aphasia, and hemiplegia, and was documented as severely cognitively impaired. The resident's guardian, listed as the primary contact, reported not being consistently informed of changes in the resident's status or care, including illness, medication changes, and new treatments. The guardian stated that she only learned of the resident's pneumonia and antibiotic treatment after proactively contacting the facility herself. A review of the electronic medical record (EMR) revealed multiple instances where significant changes in the resident's condition or treatment were not communicated to the guardian. These included new medication orders, medication changes, catheterization for a urine specimen, respiratory changes requiring new interventions, gradual dose reduction and discontinuation of psychotropic medication, initiation of treatment for an open skin area, and ongoing weight loss. In each case, there was no documentation that the guardian had been notified. The Director of Nursing acknowledged the lack of documentation and indicated a review would be conducted, but as of the survey exit, no evidence was provided that the guardian had been informed of these matters.
Failure to Review, Revise, and Implement Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and implemented for two residents. For one resident with muscular dystrophy and dysphagia, the care plan did not include a newly ordered intervention of a floor mat after a fall, and the mat was observed not to be in place at the bedside as required. Additionally, this resident's nutrition care plan required supervised dining in specific areas, but she was repeatedly observed eating unsupervised in her bed, contrary to the documented interventions. For another resident with traumatic brain dysfunction and significant cognitive impairment, the care plan addressing communication difficulties had not been updated with new interventions since 2020. The care plan called for the use of a communication board and monitoring of frustration levels, but no communication board was found in the resident's room, and there was no documentation of monitoring in the medical record. Staff reported ongoing difficulty understanding the resident, and the resident indicated he did not have or know about a communication board.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to follow professional standards of nursing practice in the administration of medications for two residents. For one resident with a diagnosis of muscular dystrophy and dysphagia, the care plan did not include any entry permitting self-administration of medications, and the most recent evaluation for self-administration was completed prior to the diagnosis of dysphagia. Despite this, staff routinely left a cup of medications on the resident's tray table, allowing her to take them at her own pace without direct observation. Facility staff confirmed that, due to the resident's dysphagia, medications should not have been left unattended and should have been administered under direct observation to ensure safety. For another resident with chronic obstructive pulmonary disease (COPD), a registered nurse prepared and administered morning medications, including a Breztri Aerosphere inhaler, which had specific instructions to rinse and expectorate after use. The nurse handed the inhaler to the resident, who self-administered it, but did not instruct or observe the resident to rinse her mouth as directed. When questioned, the nurse was unaware of the requirement to rinse and did not consult the medication administration record or provide further clarification. Facility policies required that medications be administered as ordered, in accordance with professional standards and manufacturer specifications, and that staff refer to drug reference materials if unfamiliar with a medication. In both cases, the facility did not adhere to its own policies or professional standards, resulting in deficiencies in medication administration practices for the two residents.
Failure to Follow Insulin Administration Orders and Blood Sugar Monitoring Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs in the administration and monitoring of insulin for three residents. For one resident with muscular dystrophy and diabetes, insulin was administered even when blood sugar levels were below the ordered threshold, and there was no documentation explaining the rationale for giving insulin outside of the prescribed parameters. Another resident with type 1 diabetes had multiple instances of extremely high blood sugar readings, but there was no documentation that the provider was notified as required by the physician's order. The facility's staff confirmed that there was no record of provider notification or new orders in response to these abnormal results. Additionally, a third resident with type 2 diabetes did not have blood sugar assessments completed on several days, despite documentation on the medication administration record indicating otherwise. There was no evidence in the electronic medical record that the assessments were performed or any rationale provided for missing the assessments. The facility's policy requires that vital signs be obtained and recorded per physician orders and that medications be held if parameters are not met, but these procedures were not followed in the cases reviewed.
Failure to Provide Proper CPAP Device Care and Maintenance
Penalty
Summary
The facility failed to provide proper care and maintenance of a Continuous Positive Airway Pressure (CPAP) device for a resident diagnosed with Obstructive Sleep Apnea. The resident was observed on two separate occasions with a CPAP device that was not in use, and the mask was not stored in a bag as required by facility policy. The CPAP filter was found to be moderately soiled during both observations, and the resident reported that staff had not cleaned the device in a long time. The resident also indicated that the storage bag provided by the facility was the same one given years prior, and staff did not check daily for proper storage or cleaning of the device. Review of the Medication Administration Record (MAR), Treatment Administration Record (TAR), and electronic medical record (EMR) tasks for the previous thirty days showed inconsistent documentation regarding the cleaning and maintenance of the CPAP device. While documentation alleged that the mask was cleaned once or twice daily and the filter was cleaned or changed weekly, direct observation contradicted these records, as the filter remained soiled and the mask was not properly stored. Facility policy required daily cleaning of the mask, weekly cleaning of the filter, and monthly replacement of the storage bag, none of which were consistently followed for this resident.
Failure to Properly Dispense and Document Controlled Medications
Penalty
Summary
The facility failed to ensure proper dispensing and documentation of controlled medications for three residents. For one resident with osteoporosis, tramadol was documented as dispensed on several dates, but the Medication Administration Record (MAR) showed it was not administered, and there was no documentation explaining the discrepancy. On another date, the MAR indicated the medication was administered, but there was no corresponding record of it being dispensed. The Director of Nursing confirmed a documentation error regarding the administration and disposal of the medication. Another resident with an anxiety disorder received a dose of alprazolam that was dispensed without an active physician order, and there was no documentation in the MAR or electronic medical record to support the administration or the existence of a one-time verbal order. For a third resident with anxiety disorder, lorazepam was dispensed on multiple occasions, but the MAR and electronic medical record lacked documentation of its administration. The facility's policy requires accurate accountability and documentation for all controlled substances, including when doses are administered, refused, or destroyed, but these procedures were not followed in the cited cases.
Medication Error Rate Exceeds 5% Due to Incorrect Dosages
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.66% during the observed medication administration task. For one resident with a diagnosis including vitamin D deficiency, an LPN administered 2000 IU of cholecalciferol instead of the prescribed 1000 IU. This error was identified through observation and review of the Medication Administration Record (MAR), which confirmed the incorrect dosage was given. Another resident with chronic pain syndrome, back spasm, and neuropathy received 40 mg of morphine sulfate oral solution on multiple occasions, despite the MAR indicating a prescribed dose of 20 mg. Both an RN and another nurse administered the higher dose, and the Controlled Substance Proof-Of-Use Record corroborated the administration of the incorrect amount. The facility's medication administration policy requires adherence to the six rights of medication administration, including the right dosage and review of the MAR, which was not followed in these instances.
Failure to Properly Label Medications in Medication Cart
Penalty
Summary
During an inspection of the Northeast/Northwest Split Medication Cart, surveyors observed that certain medications were not properly labeled in accordance with professional standards. Specifically, an Incruse Ellipta discus and a Fluticasone propionate nasal spray, both stored in boxes labeled with a resident's name, were found without any resident identifying information on the actual medication containers themselves. Licensed nursing staff confirmed during interviews that these items should be labeled with the resident's name to ensure correct administration and to identify ownership if the medications become separated from their boxes.
Failure to Complete Annual Performance Reviews and Provide Regular In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least once every 12 months and did not provide regular in-service education based on the outcomes of these reviews. Review of the facility's assessment indicated that while there was an orientation process and ongoing training plan in place, actual implementation was lacking. Specifically, review of employee files showed that one CNA, hired in December 2023, had no performance evaluations completed since hire, and only minimal education was documented, with a significant gap in ongoing training. Another CNA, hired in October 2022, also had no performance evaluations completed for 2023 or 2024. During an interview, the Nursing Home Administrator confirmed that performance evaluations had not been conducted in 2024 due to a hold placed by the HR department to streamline the process, and was unsure if evaluations had been completed in 2023. The administrator stated that yearly education was provided through a computerized training program, bi-monthly meetings, and a yearly skills assessment/in-service, but documentation reviewed did not support that regular in-service education or performance reviews were consistently completed as required.
Failure to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a clean and odor-free environment for two residents with environmental concerns. Observations revealed a persistent and strong smell of urine in the hallways and specific resident rooms, particularly around the Nurse's Station and in the rooms of two residents. One resident, who was occasionally incontinent and had vision problems, frequently urinated on and around the toilet, resulting in wet floors. Staff reported that it was common for the bathroom floor to be wet with urine and that housekeeping was often called to clean up. Another resident, who used urinals at the bedside due to medical conditions, was observed to have multiple urinals, some full and some empty, left on the floor and on a wastebasket in the room. The smell of urine was consistently noted in this resident's room during multiple observations. Resident Council Meeting Minutes further documented ongoing concerns from residents about inadequate cleaning of toilets and careless dumping of bedpans and urinals, leading to messy and unclean conditions. These findings were corroborated by both staff interviews and direct observations, indicating a pattern of insufficient cleaning and maintenance of resident areas, particularly in relation to the management of incontinence and urinal disposal.
Failure to Provide Appropriate Drinking Cup for Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident by not providing an appropriately sized drinking cup. The resident, who has dementia, anxiety disorder, weakness, and aphasia, was observed with a large plastic mug that she could not lift due to her lack of strength. Despite repeated requests from the resident's family member during care conferences and direct communication with staff, the facility only temporarily provided a suitable Styrofoam cup. The resident's care plan explicitly stated the need for smaller cups, yet this was not consistently adhered to, leading to concerns about potential dehydration, especially during the family member's absence.
Failure to Investigate and Report Alleged Misappropriation
Penalty
Summary
The facility failed to investigate and report an allegation of misappropriation involving a resident's missing cell phone and money to the state survey agency. The resident, who was cognitively intact, reported that her cell phone and a baggy with quarters went missing shortly after her admission. Despite the resident's reports to various staff members, including floor staff, the social worker, and administration, there was no documentation of any concern forms or incident reports being filed regarding her allegations. The Nursing Home Administrator (NHA) was unaware of the resident's allegations until informed by the surveyor. Upon learning of the situation, the NHA planned to fill out a concern form and search for the missing items. However, the facility did not report the allegations to the state survey agency within the required timeframe, nor did they provide documentation of an initiated investigation by the time of the survey's completion. This inaction was contrary to the facility's policy, which mandates immediate reporting of such allegations.
Inadequate Oral Care and Mobility Assistance for Resident
Penalty
Summary
The facility failed to provide adequate oral care for a resident with multiple sclerosis, cognitive communication deficit, and contractures. The resident's guardian reported that oral care was not being performed regularly, and the staff were not using the oral moisturizer gel provided to keep the resident's mouth moist. Observations confirmed that the resident's mouth was often dry with caked secretions, indicating a lack of routine oral care. Certified Nursing Assistants (CNAs) admitted to providing oral care less frequently than required, with one CNA stating she attempted oral care once a day, despite the resident's care plan indicating the need for oral care every two hours. Additionally, the resident was not being assisted to get out of bed and into his electric wheelchair as desired, which was another concern raised by the guardian. The resident's care plan specified that he should be in his wheelchair twice a day, but this was not consistently happening. The Unit Manager confirmed that staff training for oral care was provided, and residents were expected to receive oral care at least every two hours, which was not being adhered to in this case.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities for two residents, R7 and R16, as observed during a survey. R7, a female resident with diagnoses including dementia, Alzheimer's disease, major depressive disorder, and anxiety disorder, was observed sleeping during the day on multiple occasions. Interviews with CNAs revealed that R7 typically sleeps all day and is most alert at night, but the Activity Director (AD) was unaware of this routine and had no documentation of activities provided to R7 in the past 30 days. R7's care plan indicated a goal of participating in one-on-one activities three times a week, but there was no evidence of this being implemented. Similarly, R16, another female resident with dementia and anxiety disorder, was observed sleeping in bed, and the AD confirmed that there was no documentation of activities provided to her in the last 30 days. R16's care plan included participation in group activities like arts and crafts and bingo, but due to a shortage of volunteers, these activities were not provided. A family member expressed concern about the lack of activities for R16, especially when they were not present to engage with her.
Failure to Apply Hand Splints for Resident with Contractures
Penalty
Summary
The facility failed to provide appropriate care for a resident with contractures by not applying hand splints as required. The resident, who has multiple sclerosis, cognitive communication deficit, and contractures, was observed multiple times without the necessary hand splints. The resident's guardian reported that the splints were not being worn anymore and when they were, they were not applied correctly, causing discomfort. Certified Nursing Assistants (CNAs) were observed not applying the splints, and some were unaware of the schedule for splint application. The splints were found in the resident's dresser drawer, indicating they were not being used as per the care plan. Documentation inconsistencies were noted, with the Splints On? Task List showing discrepancies in the recorded times the splints were supposedly on. The Kardex indicated a schedule of 3 hours on and 2 hours off for the splints, but this was not adhered to, and there were no physician orders for the splints. Interviews with staff, including the Physical Therapy Director and the Unit Manager, confirmed the resident was supposed to have a schedule for splint application, but this was not being followed, leading to the deficiency.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure that expired medications were not present in one of the two medication carts inspected, specifically the Northwest Medication Cart. During an inspection with an LPN and the DON, it was observed that an opened bottle of Senna Syrup had an expiration date of January 2024, and an opened bottle of a multivitamin had an expiration date of March 2024. Both the LPN and the DON verified these findings, indicating a lapse in the facility's adherence to medication management protocols. Additionally, the facility did not secure one of the four medication carts, the Southwest Medication Cart, which was found unlocked and unattended in the hallway. RN E, responsible for this cart, admitted to leaving it unlocked while administering medications two rooms away, despite not being able to see the cart from the resident's room. Interviews with other nursing staff, including LPN F, RN B, and LPN D, confirmed that the standard procedure is to lock medication carts when unattended to secure the medications. However, it was noted that LPN D had also left her cart unlocked twice that morning, further highlighting the facility's failure to comply with its own medication storage policy.
Failure to Safeguard Resident Medical Records
Penalty
Summary
The facility failed to safeguard the confidentiality of medical records for two residents, resulting in the potential for unauthorized access to their personal health information. During an observation, the computer screen on the Southwest Medication Cart was left open, displaying a resident's electronic Medication Administration Record (e-MAR) with personal and health identifying information visible to anyone passing by. The nurse responsible for the cart was not present, and when interviewed, she did not perceive an issue with leaving the screen open, despite being unable to see the cart from her location. Another observation revealed a similar situation with a different resident's e-MAR left open on the same medication cart. Interviews with other nursing staff confirmed that the facility's policy requires computer screens to be closed when not attended, to protect residents' health information in compliance with HIPAA regulations. Despite this policy, one nurse admitted to leaving her screen open twice that morning, acknowledging the breach of protocol. The facility's HIPAA Security Measures policy emphasizes the importance of protecting electronic protected health information (EPHI) by restricting access to workstations.
Failure to Provide Collaborative Hospice Care
Penalty
Summary
The facility failed to provide collaborative hospice care for two residents, R4 and R7, who were under hospice care. For R4, the facility staff, including a registered nurse and certified nurse aides, were unaware of the last time hospice staff provided services or when they were scheduled to see R4 again. There was no documentation or schedule available at the nursing station, and the last hospice progress note in R4's electronic medical record was dated over a week prior. R4 was observed in a state of distress, having vomited on herself, and preferred hospice staff for her showers, which had not been documented as provided. For R7, the facility staff, including certified nurse aides and a social worker, were unable to verify the hospice schedule or confirm that hospice was aware of R7's sleep patterns, which involved sleeping during the day and being awake at night. The last hospice progress note for R7 was dated nearly two weeks prior, and there was no indication of hospice services being provided since then. R7 had a history of significant weight loss, refusal of meals, and increased sleep, with no recent changes in her care plan to address these issues.
Improper Cleaning of Glucometer Leads to Infection Risk
Penalty
Summary
The facility failed to properly clean a glucometer according to the manufacturer's instructions, which led to a potential risk of infection spread among residents. Observations revealed that two residents, one with diabetes and another with dementia, had their blood glucose levels checked using a glucometer that was cleaned inadequately. Licensed Practical Nurses (LPNs) were seen using 70% isopropyl alcohol prep pads to quickly swipe the glucometer, contrary to the manufacturer's guidelines that require specific EPA-approved disinfecting wipes containing bleach or a combination of germicidal ingredients. Interviews with staff, including LPNs and a Registered Nurse (RN), indicated a misunderstanding or lack of adherence to the proper cleaning protocol. Some staff believed that alcohol pads were sufficient for cleaning, while others acknowledged that only specific germicidal wipes should be used. The facility's policy and the manufacturer's instructions both emphasize the need for using appropriate disinfectants and ensuring the correct contact time to effectively sanitize the equipment. The improper cleaning practices observed could lead to the spread of infections, as the glucometer is a shared device among residents.
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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