Optalis Health And Rehabilitation Of Sterling Heig
Inspection history, citations, penalties and survey trends for this long-term care facility in Sterling Heights, Michigan.
- Location
- 38200 Schoenherr Road, Sterling Heights, Michigan 48312
- CMS Provider Number
- 235665
- Inspections on file
- 32
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Sterling Heig during CMS and state inspections, most recent first.
A resident with impaired cognition, cervical fracture, and muscle wasting was care planned and coded on the MDS as dependent for bed mobility and requiring a two-person assist. Despite this, a CNA provided perineal care alone and repositioned the resident, during which the resident moved and rolled out of bed. The resident subsequently complained of right leg pain and was later found to have a right femur fracture requiring surgery. The DOR confirmed the ongoing need for two-person assistance for safety, and the DON stated the expectation that two staff be present when a resident is care planned as a two-person assist, which did not occur in this incident.
A resident with Alzheimer's disease, severe cognitive impairment, restlessness, agitation, and aggression toward staff was admitted on a scheduled antipsychotic (Olanzapine) with physician orders for a psych consult related to aggressive behaviors. However, consent for psychiatric services was not obtained until about three months after admission, and no psych visit notes were available in the record or provided to surveyors. Social work staff reported that the standard process is to obtain psych consent at admission for residents on regular antipsychotics and to send a referral, but they could not explain why this was not done. This was inconsistent with the facility’s Behavioral Health and Management policy requiring necessary behavioral health care and services in accordance with the resident’s plan of care.
Surveyors identified several deficiencies in food service safety, including mold-like buildup and leaking equipment in the kitchen, undated and expired food items in storage, dishwashing equipment failing to reach required sanitization temperatures, expired ice machine filters, and a staff member failing to perform hand hygiene before handling food. These issues were confirmed by facility staff and were not in accordance with professional standards.
The facility did not keep the exterior dumpster area clean, as the ground was observed to be soiled with grease, sludge, and a milky liquid, along with a foul odor. Staff interviews confirmed that maintenance was responsible for cleaning the area, which had not been cleaned recently.
Surveyors identified that the facility did not maintain an active water management program, with required team members uninvolved and key monitoring activities, such as disinfectant checks and fixture flushing, not completed or documented. Additionally, staff failed to use required PPE, specifically gowns, during high-contact care for a resident on Enhanced Barrier Precautions, and did not perform hand hygiene during medication administration. The facility also lacked documentation of monthly infection control surveillance as required by policy.
Several residents with intact cognition reported that food was frequently cold and unpalatable, a concern also reflected in resident council meeting minutes. Food temperature testing confirmed that meals were served below the preferred temperature, and the use of foam containers due to a broken dishwasher contributed to the issue. The dietary manager and survey team acknowledged that the food was cold and not appetizing, failing to meet facility standards.
A resident with severe cognitive and physical impairments was initially placed on Contact Isolation for C. difficile and later required Enhanced Barrier Precautions (EBP) due to tube feeding. The care plan was not updated to reflect the change from Contact Isolation to EBP, despite physician orders and ongoing EBP signage, resulting in the care plan containing outdated information.
Three dependent residents with severe cognitive and physical impairments were not provided timely assistance with ADLs, including repositioning and brief changes, and did not have consistent access to their call lights. Observations showed residents left in bed for extended periods, call lights placed out of reach, and care needs unmet despite facility policy and staff awareness of required standards.
Two residents with severe cognitive impairment and high dependency were not provided with meaningful activities, despite documented preferences and care plans indicating the importance of such engagement. Both were observed in bed without any form of stimulation, and activity records showed no evidence of independent, intellectual, physical, social, or spiritual activities being offered or documented. Facility staff confirmed the lack of activity provision and documentation, contrary to facility policy.
A resident with a history of paraplegia and hypertension experienced ongoing post-menopausal vaginal bleeding, which was repeatedly documented by staff and reported by the resident. Despite recommendations for GYN follow-up, delays in arranging specialist care occurred due to transportation issues, scheduling difficulties, and unclear staff responsibilities. The resident's symptoms persisted and worsened over several months before a diagnosis of endometrial carcinoma was made following a delayed surgical procedure.
A resident requiring one to two-person assist for transfers and bed mobility fell from bed during incontinence care when a CNA, working alone, rolled the resident away from herself, resulting in injury and prolonged time on the floor. The facility's policy did not address fall prevention interventions.
A resident with severe cognitive impairment and total dependence on staff was observed receiving tube feeding at a rate lower than the physician-ordered amount, with no documentation to support the change. The tube feeding formula bag in use was also not changed within the required 24-hour period, contrary to facility policy. Nursing staff and the DON confirmed the expectation to follow physician orders and change bags as directed.
A resident with a history of cerebral infarction, hypertension, and muscle weakness was found with a medication cup containing two pills left on their overbed table, with no awareness of how long the medications had been there. An LPN had provided the medications but did not ensure they were taken, and there was no assessment for self-administration in the medical record. The DON confirmed that medications should not be left at the bedside, and the facility's policy did not address this issue.
Two CNAs did not have documentation of completing the required 12 hours of annual in-service training, including dementia care and abuse prevention. The facility's records were incomplete, and the staffing policy did not address the annual training requirement.
A resident with impaired cognition and severe malnutrition was admitted without pressure ulcers and placed on preventative measures. Later, an open area was discovered on the coccyx and groin, but the wound was not timely assessed, staged, or measured by the wound care team or licensed nurse, as required by facility policy. The wound care nurse awaited the weekly visit from the wound care nurse practitioner, who did not assess the wound before the resident's hospital transfer.
A resident who required extensive assistance for incontinence care experienced a delay of approximately one hour in being changed after having a soiled brief. The resident, who was cognitively intact, documented the incident and reported similar past issues. A grievance was filed by the resident's representative, and the CNA involved received a written warning for failing to complete the assigned task. The facility's policy required timely assistance based on resident needs, which was not followed.
A resident at high risk for pressure ulcers developed a Stage III ulcer due to the facility's failure to implement timely and effective preventative measures. Despite being identified as very high risk, the facility did not consistently follow prescribed skin care treatments, and necessary pressure-reducing support surfaces were not provided until after the ulcer worsened. Interviews with staff highlighted a lack of adequate preventative measures and support surfaces, and the facility's guidelines did not address necessary interventions.
The facility failed to provide and document adequate assistance with ADLs for two dependent residents. One resident with dementia and other health issues received minimal bathing assistance, while another with multiple sclerosis reported not knowing their shower schedule and expressed hygiene concerns. Both residents require significant assistance, and the facility acknowledged the need for improvement in documentation.
The facility failed to ensure safe food storage and maintain sanitary conditions in the kitchen. Observations included improperly cooled pork roasts, raw meat stored next to cooked meat, a soiled microwave, and expired food items in nourishment room refrigerators. The Certified Dietary Manager confirmed these issues.
A resident with Parkinson's Disease and Dementia had a peripheral intravenous line (PIV) that was not labeled, dated, or removed after completing IV therapy. The resident expressed discomfort and requested its removal. The facility's policy required the PIV to be removed if not used for 24 hours and the dressing to be labeled, which was not followed.
The facility failed to identify and document targeted behaviors, non-pharmacological interventions, and monitor side effects of a prescribed psychotropic medication for a resident. The resident was excessively sedated, often lethargic, and not consuming meals, with inadequate documentation and attempts of non-pharmacological interventions prior to medication increases.
The facility failed to store medication securely and monitor refrigerator temperatures properly. Unlocked medication carts were observed on multiple occasions, and temperature logs for a medication refrigerator were found to be incomplete for several dates. The facility's policies on medication storage and temperature monitoring were not adhered to.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to follow the resident’s care plan requiring two-person assistance for bed mobility, which resulted in a fall and subsequent right femur fracture. The resident was admitted with cervical fracture and muscle wasting/atrophy and had a BIMS score of 3/15, indicating impaired cognition. The most recent MDS documented the resident as dependent for bed mobility, and the ADL care plan dated 11/14/2025 specified a two-person assist for bed mobility. The Director of Rehabilitation confirmed that this resident required two staff during care for safety and remained a two-person assist for bed mobility. On 12/31/2025, during perineal care, a CNA provided care alone and repositioned the resident toward themselves. During this care, the resident, described by the LPN as very antsy, moved and rolled out of bed. An incident report documented that the resident complained of right leg pain, could not move the right lower leg, and was assisted back to bed by two staff, with vital signs taken and a STAT X-ray ordered. A subsequent physician readmission note dated 1/15/2026 documented that the resident was sent back to the hospital for possible trauma and was found to have a right femur fracture requiring surgery in the OR. The DON stated that the expectation is that when a resident is care planned as a two-person assist, there should be two people in the room, indicating that this expectation was not met at the time of the fall.
Failure to Timely Initiate Psychiatric Services for Resident on Antipsychotic Therapy
Penalty
Summary
The facility failed to provide necessary behavioral health care and services by not timely initiating psychiatric services for a resident admitted with significant behavioral and cognitive issues. The resident was admitted with Alzheimer's disease, restlessness, and agitation, and had a Brief Interview for Mental Status score of 0/15, indicating severely impaired cognition. The resident required staff assistance with bed mobility and transfers. Physician orders at admission included scheduled Olanzapine 5 mg orally every 12 hours as an antipsychotic and a psychiatric consult related to aggression toward staff, including throwing water at staff and refusing care, with consult start dates documented as 9/9/2024 and 10/13/2024. Despite these orders and the resident’s behavioral concerns, the medical record showed that consent to receive psychiatric services was not obtained until 12/12/2024, approximately three months after admission. No psychiatric visit notes were available in the record and were not provided to surveyors upon request. Social work staff interviewed during the survey stated that the usual process is to obtain consent for psychiatric services upon admission for residents on regular antipsychotic medications and to send a referral to the psychiatric provider, but they were unable to explain why this did not occur for this resident. The facility’s Behavioral Health and Management policy states that it is the policy of the facility to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents in accordance with their plan of care, which was not followed in this case.
Multiple Food Service Safety and Sanitation Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in food service safety and sanitation within the facility's kitchen. There was a buildup of a black, mold-like substance on the backsplash of the dish machine, and the faucet assembly for the hose sprayer was leaking water. In the walk-in cooler, opened containers of ranch and Greek dressing were found undated, and a container of cut carrots and celery was dated beyond the acceptable range and appeared dried out. The Dietary Manager confirmed that the dressings should have been dated and the vegetables discarded. The dish machine was tested and found not to reach the required sanitization temperature, with the Dietary Manager acknowledging ongoing issues and a pending replacement. Additionally, ice machine filters in several locations were observed with expired dates, and the Maintenance Supervisor confirmed they were overdue for replacement. Further, a dietary staff member was observed entering the kitchen and beginning work on the lunch trayline without performing required handwashing. The Dietary Manager confirmed that handwashing should have occurred before handling food items. These observations were all in direct violation of specific sections of the 2022 FDA Food Code regarding cleanliness, equipment maintenance, food labeling and dating, temperature requirements for dishwashing, and hand hygiene.
Improper Maintenance of Exterior Dumpster Area
Penalty
Summary
The facility failed to maintain the exterior trash refuse area in a clean and sanitary condition. During observation, the ground around both dumpsters was found to be soiled with grease and sludge, and a milky liquid was pooled on the ground, accompanied by a foul, sour odor. The Dietary Manager indicated that Maintenance was responsible for cleaning the dumpster area, while the Maintenance Supervisor stated that the area is typically cleaned monthly and acknowledged it was likely due for cleaning again. These findings were confirmed through observation, staff interviews, and reference to the 2022 FDA Food Code requirements for refuse area maintenance. No specific residents were directly involved or affected at the time of the deficiency, but the condition of the refuse area had the potential to impact all residents, staff, and visitors.
Deficiencies in Water Management and Infection Control Practices
Penalty
Summary
The facility failed to maintain an active and ongoing Water Management Program Plan (WMPP) to reduce the risk of Legionella and other opportunistic pathogens in the plumbing system. The WMPP required the establishment of a Water Management Team, including the Administrator, Maintenance Director, and Infection Preventionist, to implement policies, monitor performance, and review the program annually. However, interviews revealed that the Infection Preventionist and Administrator were not actively involved, with responsibilities deferred entirely to the Maintenance Supervisor. The plan had not been updated since 4/29/23, and required monitoring activities such as Point of Use Residual Disinfectant checks and fixture flushing logs were not being completed or documented, as confirmed by the Maintenance Supervisor. The facility also failed to ensure proper use of Personal Protective Equipment (PPE) during isolation precautions and did not complete departmental infection control surveillance. Observations showed that staff providing care to a resident on Enhanced Barrier Precautions (EBP) wore only gloves, not gowns as required by signage and physician orders, during high-contact activities such as bathing, brief changes, and PEG tube care. Additionally, a nurse was observed failing to perform hand hygiene during a medication pass. The Infection Control Preventionist confirmed that the required PPE was not used and that there was no documentation of monthly departmental infection control surveillance. The resident involved in the PPE deficiency had significant medical needs, including non-traumatic brain dysfunction, stroke, high blood pressure, severely impaired cognition, impaired range of motion, and total dependence on staff for activities of daily living. The resident was on EBP due to a PEG tube and had previously been on contact precautions for a stool-borne pathogen. The facility's infection surveillance policy required monthly data analysis and presentation to the QAPI committee, but no such documentation was available at the time of the survey.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to ensure that food was served in a palatable manner and at a safe, appetizing temperature for several residents. Multiple residents with intact cognition reported that the food did not taste good and was frequently cold when served. These concerns were echoed by five residents during a group interview and were also documented in resident council meeting minutes over several months, which noted that meals were cold and the overall quality of food needed improvement. Specific residents interviewed had medical conditions such as cellulitis, heart disease, fracture of the right lower leg, muscle weakness, spondylolisthesis, heart failure, and depressive disorder. During an observation, a breakfast tray was tested for temperature and found to be below the preferred standard, with pancakes at 105°F and turkey sausage at 103°F, while the dietary manager indicated the desired temperature was 130°F or greater. The food was served in white foam containers due to a broken dishwasher, and the dietary manager acknowledged that these containers did not maintain food temperature well. Survey team members confirmed that the food tasted cold, which negatively impacted its palatability. The administrator confirmed that the expectation was for food to meet all temperature standards.
Failure to Update Care Plan Following Change in Isolation Precautions
Penalty
Summary
A resident with diagnoses including non-traumatic brain dysfunction, stroke, and high blood pressure was admitted to the facility and assessed as having severely impaired cognition, impaired range of motion, and total dependence on staff for all activities of daily living. The resident was initially placed on Contact Isolation Precautions for C. difficile shortly after admission, and later, a physician's order directed that Enhanced Barrier Precautions (EBP) be implemented every shift due to tube feeding. Despite these changes, the resident's care plan, last revised on the date of the initial isolation, was not updated to reflect the new EBP order. Observations during the survey confirmed that EBP signage was present on the resident's door, and interviews with the Infection Preventionist and DON revealed that the care plan should have been updated immediately to reflect the change from Contact Isolation to EBP. The care plan continued to reference the discontinued C. difficile precautions and did not include the current EBP requirements, indicating a failure to revise the care plan in accordance with the resident's updated care needs and physician's orders.
Failure to Provide Timely ADL Care and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to provide timely care and assistance with activities of daily living (ADLs), including repositioning, brief changes, and ensuring call light accessibility, for three dependent residents. Observations revealed that residents with severe cognitive impairment and physical limitations, such as those with diagnoses of non-traumatic brain dysfunction, stroke, high blood pressure, Alzheimer's, anxiety, depression, and dementia, were left in bed for extended periods without being repositioned or assisted out of bed. In multiple instances, residents' call lights were found out of reach, placed in closed drawers, and not accessible to the residents, despite facility policy requiring call lights to be within reach and functioning. One resident was observed multiple times over several days lying supine in bed, dressed in a hospital gown, with their breakfast tray untouched and the call light inaccessible. The resident expressed a desire to be out of bed but was not observed to have been assisted with transfers or repositioning, and staff confirmed the resident required a Hoyer lift and two-person assistance. Another resident was observed with long, dirty fingernails, a saturated brief, and reported not having been changed or repositioned recently. Staff interviews confirmed knowledge of the facility's two-hour repositioning and brief change policy, but observations indicated these standards were not consistently met. Additionally, a third resident was observed repeatedly activating their call light to request a brief change, but staff deactivated the call light without providing care and left the room. Agency staff admitted to not knowing the call light policy. Resident council meeting minutes documented ongoing concerns about untimely call light responses and lack of care. Interviews with nursing leadership confirmed expectations for timely call light response and care provision, but these were not consistently followed as evidenced by the observations and resident reports.
Failure to Provide Meaningful Activities for Dependent Residents
Penalty
Summary
The facility failed to provide appropriate and meaningful activities for two residents with severe cognitive impairment and high dependency for activities of daily living. Both residents were observed in their rooms, in bed, without any form of engagement such as television, music, or other devices during multiple days and times. Record reviews indicated that both residents had documented preferences for activities such as listening to music, keeping up on the news, participating in group activities, and going outside. Care plans for both residents included encouragement to attend activities of their choice and assistance with attending special events or going off the unit. However, activity task documentation showed no evidence that any independent, intellectual, physical, social, or spiritual activities were provided to either resident during the reviewed period. Interviews with the Activities Director confirmed that room visits are intended for residents who are bedbound or do not leave their rooms, but there was no documentation of any such activities for the two residents in question. The Director of Nursing also confirmed that care activities should be provided and documented. Facility policies require an ongoing program of activities to meet the interests, choices, and preferences of each resident, supporting their physical, mental, and psychosocial well-being, as well as their right to participate in activities programs of their choice. Despite these policies, the facility did not provide or document activities for the two residents reviewed.
Failure to Provide Timely Gynecological Care for Resident with Abnormal Uterine Bleeding
Penalty
Summary
A deficiency occurred when the facility failed to provide timely gynecological care for a resident experiencing post-menopausal vaginal bleeding. The resident, who had a history of paraplegia, adjustment disorder, and hypertension, reported intermittent vaginal bleeding beginning in June 2024. Despite multiple progress notes documenting the resident's ongoing symptoms and requests for gynecological evaluation, there were significant delays in arranging appropriate specialist care. The initial assessment by the facility's nurse practitioner ruled out a urinary tract infection, but no further investigation was pursued for several months, even as the resident's symptoms persisted and sometimes worsened to heavy and painful bleeding. The resident's medical record showed repeated documentation of abnormal uterine bleeding, with recommendations for gynecological follow-up made by both the primary care provider and facility staff. However, logistical challenges, such as the need for stretcher transportation and difficulties in scheduling with a gynecologist who could accommodate the resident's bedbound status, led to multiple missed and rescheduled appointments. Interviews with staff revealed a lack of clarity regarding responsibility for scheduling these appointments, with the unit clerk unaware of the need for gynecological care until several months after the initial symptoms were reported. Social work staff indicated their role was limited to ancillary services, and the director of nursing was not familiar with the concern. Throughout this period, the resident continued to experience vaginal bleeding, which was observed by direct care staff and reported to nursing. The resident ultimately received a diagnosis of mixed high-grade endometrial carcinoma after a significant delay, following a surgical procedure performed under anesthesia. The facility's failure to ensure timely specialist evaluation and coordination of care, despite ongoing symptoms and repeated documentation of the need for follow-up, resulted in a delay in diagnosis and treatment of a serious medical condition.
Failure to Prevent Resident Fall During Incontinence Care
Penalty
Summary
A deficiency occurred when a resident with a history of nontraumatic intracerebral hemorrhage, diabetes, and heart failure, who was cognitively intact and required assistance from one to two staff for transfers and bed mobility, sustained a fall during incontinence care. The resident was being assisted by a single CNA, despite requiring up to two-person assistance, and the CNA rolled the resident away from herself, resulting in the resident falling out of bed onto the floor. The resident reported pain to the right upper and lower extremities and remained on the floor for approximately 30-45 minutes while staff located a mechanical lift to return them to bed. Documentation and interviews confirmed that the CNA was working alone and did not follow proper transfer technique, which was acknowledged by both the ADON and DON. Further review revealed that the facility's provided policy, titled "Accident and Incident Report," did not address fall interventions or prevention measures. The incident was witnessed by staff who responded to a loud noise and found the resident on the floor. The resident expressed concerns about the adequacy of assistance during transfers and bed mobility, and the lack of a comprehensive fall prevention policy contributed to the failure to prevent the accident.
Failure to Properly Label, Date, and Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to properly label, date, and administer tube feeding as ordered for a resident with significant medical needs. The resident, who had diagnoses including non-traumatic brain dysfunction, stroke, and high blood pressure, was assessed as having severely impaired cognition and was dependent on staff for all activities of daily living, including eating. Observations over two days showed the resident receiving tube feeding at a rate of 40 ml/hr, while the physician's order specified a rate of 45 ml/hr. There was no documentation in the progress notes or orders to justify the deviation from the prescribed rate. Additionally, the tube feeding formula bag in use was observed to be dated from the previous day, exceeding the facility's policy to change the bag every 24 hours. Interviews with nursing staff and the DON confirmed that the policy requires tube feeding bags to be changed and dated every 24 hours and that physician orders should be followed precisely. The facility's own policy also mandates that tube feedings be administered according to current clinical standards and physician orders, including specific instructions for feeding type, rate, and bag changes.
Medications Left Unattended at Bedside
Penalty
Summary
A deficiency occurred when a medication cup containing two pills was observed on a resident's overbed table, with the resident unaware of their presence or how long they had been there. The resident, who was cognitively intact and required minimal assistance for activities of daily living, had been admitted with diagnoses including cerebral infarction, hypertension, and muscle weakness. There was no assessment in the medical record for the resident's ability to self-administer medications. The assigned LPN reported having provided the medications to the resident while attending to the resident's roommate but did not ensure the medications were taken at that time. The LPN was unaware of why the medications had not been taken and only observed the resident take them after being prompted. The facility's Director of Nursing confirmed that medications should not be left at the bedside and that nurses are expected to watch residents take their medications. The facility's policy on medication storage did not address the issue of medications being left at the bedside.
Failure to Ensure Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs) completed the required 12 hours of annual in-service training, including education in dementia care and abuse prevention. Documentation for one CNA only included a skills competency checklist, which did not specify the number of training hours or confirm that dementia management and abuse prevention topics were covered. No training documentation was provided for the second CNA by the end of the survey. The facility relies on a vendor to provide training for agency CNAs through an app, and ongoing education is reportedly provided during work shifts. Additionally, a review of the facility's staffing policy revealed it did not address the requirement for 12 hours of annual in-service training for CNAs.
Failure to Timely Assess and Document Pressure Ulcer
Penalty
Summary
A resident with severe protein-calorie malnutrition and impaired cognition was admitted to the facility without any open pressure ulcers, as confirmed by an initial skin assessment conducted by the wound care team. Preventative measures, including a pressure-reducing mattress and repositioning protocols, were implemented due to the resident's decreased mobility. However, the resident later developed an open area on the coccyx and groin, which was first identified by a CNA and subsequently treated by nursing staff with cleansing, application of Medihoney, and a foam dressing. The medical doctor was notified, and a wound care consult was requested. Despite the development of the pressure ulcer, there was no evidence in the medical record that the wound was timely assessed, staged, or measured by the wound care team or licensed nurse, as required by facility policy. The wound care nurse stated that they were waiting for the wound care nurse practitioner, who visits weekly, but the practitioner did not assess the wound before the resident was transferred to the hospital. Wound care notes were requested but not provided by the end of the survey.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R702, who was cognitively intact and required extensive assistance from two persons for incontinence care. On a specific day, R702 experienced a delay in being changed after having a soiled brief. The resident reported waiting approximately one hour before being attended to by their assigned CNA, despite being told they would be changed sooner. This delay was documented by the resident in a notepad, which included dates, assigned staff, and wait times for care. The resident also expressed that they had experienced similar issues in the past and had attempted to plan their bowel movements around staff shifts due to long call light wait times. The incident was further corroborated by a grievance filed by the resident's representative, expressing concerns about the timeliness of incontinence care. The facility's records showed that the CNA involved received a written warning for failing to complete the assigned task and for carelessness in performing their job duties. The Director of Nursing acknowledged the incident but did not provide additional comments. The facility's policy on incontinence care stated that residents should receive assistance based on their requests or needs, which was not adhered to in this case.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to implement timely and effective interventions to prevent the development of a pressure ulcer for a resident identified as R701. Initially admitted without skin integrity issues, R701 had multiple diagnoses, including Vascular Dementia and Acute Kidney Disorder, and required extensive assistance for mobility and toileting. After a hospital transfer, R701 returned with a Stage II pressure ulcer, which later healed. However, the resident was at very high risk for pressure ulcers, as indicated by the Braden Scale, and the facility's treatment records showed lapses in the prescribed skin care regimen. Despite the high risk, the facility did not consistently follow the physician's orders for skin care, as evidenced by missed treatments on several dates. Additionally, the facility's documentation failed to identify any skin abnormalities in weekly evaluations, even as the resident's condition deteriorated to a Stage III pressure ulcer. The facility's interventions, such as the use of a custom care mattress, were not sufficient, and a low air loss mattress was not provided until after the ulcer worsened. Interviews with facility staff, including the Wound Care Nurse and Director of Nursing, revealed a lack of adequate preventative measures and support surfaces for R701. The facility's Skin and Wound Guidelines did not address the implementation of preventative interventions, contributing to the deficiency. The resident's care plan and physician orders were not updated to include necessary pressure-reducing support surfaces until the pressure ulcer had progressed to a more severe stage.
Failure to Provide and Document ADLs for Dependent Residents
Penalty
Summary
The facility failed to document and provide adequate assistance with Activities of Daily Living (ADLs) for two dependent residents, R902 and R903. R902, who has diagnoses including Dementia, Diabetes, and Heart Failure, was observed to have received only a bed bath on one occasion and a shower on another within a 30-day period, with other dates marked as Not Applicable. The resident's family expressed concerns about the lack of showers and assistance in getting out of bed. R902 is significantly cognitively impaired and requires 1-2-person assistance for bed mobility, transfers, and toileting. Similarly, R903, who has Multiple Sclerosis, Hypotension, and Bi-Polar Disorder, reported being unaware of their shower schedule and expressed concern about personal hygiene. A review of R903's records showed no documentation of showers or resident refusals, with all entries marked as Not Applicable. R903 also has significantly impaired cognition and requires assistance for transfers, toilet use, and personal hygiene. The Director of Nursing and a corporate employee acknowledged the need for improvement in documentation after reviewing the electronic medical records.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was safely stored and maintained sanitary conditions in the kitchen, as observed during an initial tour. In the walk-in cooler, two foil-covered pans with cooked whole pork roasts dated 5/13 were found with internal temperatures between 56-58 degrees Fahrenheit, which did not comply with the FDA Food Code requirements for cooling potentially hazardous food. The Certified Dietary Manager (CDM) was unable to locate the cooling logs used by kitchen staff. Additionally, raw ground beef was stored next to cooked beef patties and chopped beef, and a box of raw bacon was stored directly above the cooked beef, which violates the FDA Food Code's guidelines for preventing cross-contamination of food items. The CDM confirmed these storage issues during the inspection. Furthermore, the second-floor kitchenette had a microwave with dried, encrusted food debris, and the nourishment room refrigerators contained undated and expired food items, including containers with unknown substances and food items dated as far back as 4/7, which were not discarded as per the facility's Outside Food Policy dated 10/2/23.
Failure to Label, Date, and Remove Peripheral Intravenous Line
Penalty
Summary
The facility failed to label, date, and remove a peripheral intravenous line (PIV) for a resident who had completed their IV therapy. On 5/14/2024, the resident was observed with a PIV in their left wrist that was not labeled or dated, and an IV pump was present in the room. The resident, who had Parkinson's Disease and Dementia, stated they were not receiving any fluids through the PIV and expressed discomfort, requesting its removal. The medical record indicated that the resident had completed their IV therapy on 5/8/2024, but the PIV was still in place as of 5/14/2024. An interview with the Infection Control Preventionist (ICP) revealed that the PIV might have been left in due to the resident's hypotension, but the dressing should have been labeled and dated. The facility's policy on catheter insertion and care stated that the peripheral catheter should be removed if it has not been used for 24 hours or if the therapy is discontinued, and the dressing should be labeled with the date, time, and initials. The failure to follow these policies led to the deficiency observed during the survey.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to identify and document targeted behaviors, non-pharmacological interventions for behaviors, and monitor side effects of a prescribed psychotropic medication for one resident. The resident, who was admitted with diagnoses including Cerebral Infarction, Adjustment Disorder, Diabetes Type II, and Hypertension, was observed to be excessively sleeping and not consuming meals. Despite being severely cognitively impaired and requiring assistance for bed mobility and transfers, the resident's excessive sedation was not adequately addressed or documented in their care plan. The resident was prescribed Quetiapine upon discharge from the hospital, with the dosage being increased twice within a short period. Despite recommendations from a Medication Regimen Review to consider discontinuation or adding a supporting diagnosis, the resident continued to receive the medication. Observations and interviews with staff indicated that the resident was often lethargic, drowsy, and unresponsive, with multiple instances of the resident not participating in therapy and refusing meals. Interviews with the Nurse Practitioner and Director of Nursing revealed that non-pharmacological interventions were not adequately attempted or documented prior to the medication increases. The resident's care plan included interventions for psychotropic medication use, but there was no evidence of targeted or documented non-pharmacological attempts for behavior management. The facility's policy for unnecessary medications was not provided by the end of the survey.
Medication Storage and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store medication in a safe and secure manner for two of the nine medication/treatment carts. On multiple occasions, medication carts were observed to be unlocked and unattended, allowing residents and staff to pass by them. Specifically, on 5/14/24, a treatment cart near room 152 was found unlocked, and on 5/15/24, a medication cart on the second floor was also observed to be unlocked. The unit manager, LPN C, was informed about the unlocked cart and instructed the assigned nurse to ensure it was locked. The Nursing Home Administrator confirmed that the facility's expectation is to lock the medication cart when not in use. The facility's policy on medication and treatment storage mandates that all medications and biologicals be stored in locked compartments under proper temperature controls, which was not adhered to in these instances. The facility also failed to monitor the temperatures of a medication refrigerator that stored drugs and biologicals. During an observation on 5/16/24, the One [NAME] Unit medication refrigerator's temperature log was found to have incomplete documentation for several dates in February, March, April, and May 2024. LPN B explained that the day shift nurse is responsible for completing the temperature log on the day shift, and the afternoon nurse is responsible for its completion on the afternoon shift. Both the Nursing Home Administrator and the Director of Nursing confirmed that the expectation is for the temperature logs to be completed daily. The facility's policy requires that logs be kept on each refrigerator and temperature levels be recorded daily by the charge nurse or other designee, which was not followed in this case.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
