Optalis Health And Rehabilitation Of Troy
Inspection history, citations, penalties and survey trends for this long-term care facility in Troy, Michigan.
- Location
- 925 W South Blvd, Troy, Michigan 48085
- CMS Provider Number
- 235626
- Inspections on file
- 41
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Troy during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, dementia, severe cognitive impairment, and a guardian had a documented history of nighttime wandering into other residents’ rooms, entering roommates’ space, flooding a bathroom, urinating on the floor, grabbing a nurse’s breast multiple times, hitting a nurse on the rear, making sexual remarks to female staff, and attempting to get into bed with another resident who tried to push him away. Despite these repeated behaviors, effective care plan interventions for wandering and sexually focused behaviors were not implemented for an extended period, and the resident was moved to a unit housing many highly vulnerable residents with dementia. Later, a CNA found this resident in bed with a non-verbal, severely cognitively impaired female resident, with his hand down the front of her brief, after camera footage showed he had entered her room and remained there for over an hour without staff stationed outside his room as care-planned; staff also did not use translation tools they normally used to communicate with him, and the female resident’s guardian was not fully informed that his hand had been inside her brief.
A resident with a history of TIA and cerebral infarction reported new stroke-like symptoms, including left-sided weakness and inability to grasp with the left hand. Despite these symptoms and family concerns, staff did not provide ongoing assessment, follow recommended monitoring, or send the resident for further evaluation. The resident missed two neurology appointments before being sent to the hospital, where imaging revealed a new chronic infarct. The facility lacked a stroke protocol and did not ensure timely intervention or follow-up.
A resident with a history of gangrene and recent toe amputation experienced a worsening wound and required hospitalization after the facility failed to ensure timely wound care and specialist follow-up. The resident missed a critical appointment due to being sent to the wrong location, experienced delays in treatment, and did not receive recommended antibiotics. Staff did not consistently use translation services to address the resident's language barrier, and documentation showed lapses in communication and follow-up.
A resident with dementia, impaired cognition, and blindness, who required 24-hour supervision, was sent alone to multiple medical appointments without staff accompaniment. Despite documentation of the resident's inability to make medical decisions or provide history, facility staff failed to ensure appropriate supervision during transportation, and interviews revealed unclear procedures for determining when staff should accompany residents.
Two residents experienced significant changes in condition that were not properly identified or addressed by staff, including delayed physician notification, ineffective antibiotic treatment, and lack of timely follow-up on abnormal symptoms and test results. One resident died from septic shock secondary to UTI and pneumonia after staff failed to act on clear signs of decline, while another was transferred to the hospital for respiratory distress after delayed assessment and intervention for cardiac and respiratory symptoms.
A resident with complex medical needs experienced multiple hospitalizations after staff failed to timely identify, assess, and report changes in condition, did not consistently monitor or document vital signs before medication administration, and administered oxygen without a physician order. Incomplete nursing notes, failure to implement physician orders for IV therapy, and lack of timely transfer to a higher level of care were also observed, contributing to adverse outcomes.
A resident with severe malnutrition and dysphagia experienced significant unaddressed weight loss due to delayed nutritional assessments, lack of timely interventions, and poor interdisciplinary communication. Despite ongoing poor intake, requests for GI referral and PEG tube placement were not promptly followed up, and dietary supplements were not administered as ordered. The resident was hospitalized twice for acute changes in condition and ultimately died with severe calorie malnutrition.
A resident with a history of orthopedic injuries, requiring two-person assistance for bed mobility and incontinence care, sustained a distal tibia fracture when an agency CNA provided care alone and the resident's leg slipped off the bed and hit the floor. The CNA was not informed of the two-person assist requirement, and the facility's investigation lacked comprehensive staff interviews or evidence of staff education regarding adherence to care plans.
A resident with dementia and a history of cancer had a valid DNR order signed by both the resident and physician, but the EMR incorrectly listed the resident as "Full code." Both nursing and social work staff initially referenced the incorrect code status, only discovering the error after further review. Facility policy requires accurate documentation and display of code status, but this was not followed, resulting in staff confusion about the resident's end-of-life care wishes.
A resident with Parkinsonism and intact cognition reported being physically abused by a nurse during incontinence care after accidentally kicking the nurse out of fear of falling. The nurse allegedly struck the resident and refused to complete care, but denied the incident when interviewed. The facility substantiated the abuse based on the resident's consistent account and cognitive status, documenting violations of abuse, rudeness, and negligence by the nurse.
A resident with a history of orthopedic issues sustained a tibia and fibula fracture during care by an agency CNA. The resident reported pain and fear after the incident, but staff did not notify the Administrator or State Agency until several days later, after x-ray confirmation. Facility policy requiring immediate reporting of such incidents was not followed, resulting in a deficiency for delayed reporting of alleged abuse and injury of unknown origin.
The facility did not thoroughly investigate an injury of unknown origin and an allegation of mistreatment for a resident, and failed to prevent further access between a resident and an employee with confirmed abuse findings, as required by policy.
A dependent resident with dementia and incontinence was left yelling for assistance while staff at the nursing desk did not respond. The resident was found poorly positioned in bed, with a wet brief and the call light out of reach. Staff interviews revealed incontinence care had not been provided during the shift, and care plans for positioning and call light access were not followed, resulting in a deficiency related to timely ADL care.
Staff did not follow facility policy for assessing and documenting a resident's decision-making capacity. After concerns about cognition were raised, only one physician evaluated the resident, and the required documentation was incomplete and not properly filed. The attending physician signed the capacity form without a current face-to-face exam, and the original form was missing from the medical record.
A resident with a history of orthopedic issues sustained a leg fracture while being cared for by an agency CNA, who did not follow the care plan requiring two-person assistance. The facility's investigation was incomplete, with only one staff statement obtained and no documentation of interviews with other staff or residents, nor evidence of staff education or disciplinary action.
A resident with Parkinsonism and intact cognition reported being physically abused by a nurse during incontinence care. Despite the facility substantiating the abuse allegation and the resident's request not to be assigned to the nurse, the nurse continued to provide care and administer medications to the resident after the incident, contrary to facility policy requiring immediate removal of staff involved in abuse allegations.
The facility failed to maintain operational mechanical lifts, affecting three residents' ability to be safely transferred and participate in activities. Residents reported issues with lift batteries not holding a charge, leading to mobility restrictions and safety concerns. Staff struggled to find charged batteries and operational lifts, impacting resident care. The Maintenance Director noted that routine maintenance was delayed due to unpaid bills, and the facility lacked a proper system for logging repair needs.
The facility did not ensure grievances from residents in the resident council meetings were documented, investigated, tracked, and resolved. During a group meeting, several residents reported that their concerns were not addressed or resolved in a timely manner. A review of meeting minutes revealed concerns with nursing services, but the facility had no documentation showing these concerns were addressed. The Activities aide confirmed the absence of a grievance resolution form for the nursing services concerns.
The facility failed to meet professional standards for four residents, including incorrect documentation of a resident's status, improper medication administration, mishandling of a stool sample, and an untestable urine specimen due to labeling errors. These deficiencies highlight lapses in documentation, medication protocols, and infection control processes.
A resident with a history of intraspinal abscess, meningitis, and rheumatoid arthritis experienced discrepancies in the documentation of Hydromorphone administration. The facility's records showed tablets being removed without corresponding entries on the MAR, and times were altered on the MAR. The DON was informed of these issues, which involved eight unaccounted tablets.
The facility failed to store medications safely and appropriately, as observed in multiple medication carts. Coffee was found in a cart drawer, and several medications, including insulin and inhalers, were undated despite being opened and used. Additionally, an unlocked and unattended treatment cart was observed, which the DON confirmed was against policy. These findings indicate lapses in adherence to medication storage policies.
The facility failed to ensure proper infection control practices for two residents on transmission-based precautions, leading to potential infection spread. A CNA did not follow PPE protocols for a resident with Candida auris, and there was confusion over signage and precautions for another resident on IV antibiotics. Staff, including a new Infection Preventionist, were not fully informed about necessary precautions, resulting in inconsistent practices.
The facility failed to maintain resident dignity and respect, as evidenced by incidents involving two residents. One resident was instructed to urinate in their brief instead of being assisted to the bathroom, while another was observed without proper clothing, only wearing a brief or gown. Additionally, three anonymous residents reported feeling disrespected by staff. These incidents highlight systemic issues in the facility's approach to resident dignity.
A resident's privacy was compromised during a blood draw as the procedure was visible from the hallway due to an open door and curtain. The Unit Manager confirmed the lack of privacy, and the phlebotomist did not respond when questioned about the oversight. The resident had a diagnosis of MSSA, and the facility could not provide a privacy policy when requested.
A facility failed to document and communicate a resident's transfer to the hospital, resulting in a deficiency. The resident, with diagnoses including diabetes and dementia, was sent to the hospital, but necessary transfer documentation was not completed. The resident remained listed as active in records, and progress notes inaccurately showed the resident as present in the facility. Staff interviews revealed a lack of communication and oversight in the discharge process.
A resident admitted for rehabilitation after a fall continued to receive Trelegy Ellipta despite pharmacy recommendations against it. The DON confirmed the medication was administered without clarifying the order with the physician, contrary to facility policy requiring review of new admission orders with the physician.
The facility failed to provide adequate pressure ulcer care for two residents. One resident's heel breakdown was not communicated to the wound care nurse in a timely manner, while another resident with a stage III sacral ulcer did not receive consistent treatment as per the prescribed plan. Discrepancies in treatment orders and missed applications contributed to the deficiency.
The facility failed to conduct timely skills and competency evaluations for two CNAs, with the last evaluations completed over a year ago. The In-Service Director confirmed the lapse, noting that evaluations should be annual. Documentation provided included only a blank skills checklist.
The facility failed to complete physician-ordered lab tests for two residents, resulting in a deficiency. One resident with severe cognitive impairment and hemiplegia did not have a CBC with differential completed due to an incorrect entry in the EMR. Another resident with end-stage renal disease and cerebral infarction did not receive weekly CBC and CMP tests as ordered, with only one set of results available.
A facility failed to communicate significant changes in a resident's condition to hospice services. The resident, under hospice care for multiple medical conditions, experienced discomfort and was diagnosed with a urinary tract infection. Despite facility policy requiring notification of such changes, the hospice nurse was not informed, leading to a lack of collaboration on the resident's care plan.
The facility did not ensure nurse staffing information was accessible for residents and visitors, with missing postings on several dates over three months. The Administrator indicated the scheduler and receptionist were responsible for posting, but multiple instances of missing documentation were found.
A resident reported issues with receiving timely assistance for bathroom needs, which were not adequately addressed by the facility. Despite the resident's complaints, the facility failed to ensure timely help, as evidenced by a CNA forgetting to assist the resident after turning off their call light. The facility's grievance process was incomplete, with no formal education or documentation on call light response, leading to a deficiency in resolving the resident's grievance.
A facility failed to report an allegation of abuse involving a resident to the State Agency. The resident, with diagnoses including Morbid Obesity and a Pressure ulcer, was reportedly pushed by a CNA. The incident was reported by the resident's family, who also notified the police. Despite the police finding no evidence, the facility did not report the allegation to the State Agency, violating their policy requiring immediate reporting of such incidents.
A facility failed to follow a resident's bed mobility plan of care, which required two-person assistance. A CNA performed the task alone, contrary to the care plan, leading to a deficiency in providing adequate supervision to prevent accidents. The resident, with moderately impaired cognition, was dependent on staff for most activities of daily living.
A facility failed to ensure a CNA received required training on abuse policies before working with residents, leading to an incident where a resident was allegedly pushed by the CNA. The resident, who had impaired cognition and required assistance with daily activities, reported the incident to family, prompting a police investigation. The facility lacked documentation of the CNA's training, despite policies requiring such training upon hire and annually.
A resident reported issues with timely medication administration and lack of follow-up on grievances. Despite emailing the DON, the concern was not documented on a grievance form. The resident's medical record showed they required assistance with daily activities and had intact cognition. The facility's grievance log lacked documentation of the medication concern and other grievances were incomplete, violating the facility's grievance process policy.
A facility failed to develop a comprehensive care plan for a resident with complex urinary conditions, including recurrent UTIs with multidrug-resistant bacteria, a ureteric stent, and chronic kidney disease. Despite hospital documentation detailing the resident's medical history and treatment needs, no care plan was created to address these issues. The Director of Nursing acknowledged the oversight but did not provide further documentation.
A resident with multiple diagnoses, including dementia and sciatica, did not receive timely showers as per their care plan. Despite being cognitively intact and requiring assistance with transfers, the resident only received bed baths over three weeks after admission. Complaints were filed alleging inadequate grooming, and documentation showed no record of shower refusals or requests for bed baths, contrary to facility policy.
A resident with serious medical conditions experienced difficulty breathing, but the facility failed to perform a complete assessment or notify the physician. Despite the family's request for hospital transfer, the facility did not act, leading the family to call 911. The resident was later admitted to the ICU with sepsis, highlighting lapses in care and communication.
A resident with acute respiratory failure and hypoxia did not receive continuous oxygen as prescribed. A family member found the oxygen concentrator off and informed the nurse, who was unaware of the issue. The DON confirmed that continuous oxygen should be provided without exception, but no further documentation was provided by the facility.
A facility failed to implement a baseline care plan for a resident with chronic respiratory failure and a tracheostomy, who required continuous enteral feeding. The care plan lacked an intervention for proper positioning, which is essential for preventing complications. This deficiency was discovered after the resident was found unresponsive, highlighting the facility's failure to follow its standard practice of implementing necessary interventions upon admission.
A resident experiencing excessive menorrhagia and passing blood clots was not transferred to the hospital in a timely manner, despite family requests and police involvement. The LPN did not report the resident's elevated temperature to the physician or administer treatment, citing the planned hospital transfer as the reason for inaction. This delay and lack of communication led to a deficiency finding.
A resident with a UTI and rhabdomyolysis was found multiple times in urine-soaked bed sheets, and her son's concerns were not properly documented or addressed by the facility. Despite the facility's grievance policy, no grievance form was completed, and the resident was discharged the next day.
The facility failed to ensure consistent physician monitoring and follow-up for a resident with vaginal/urinary concerns. Despite a hospital recommendation for a urine culture and a physician order to collect urine for urinalysis and culture, the tests were not processed due to a missing order, and the physician did not follow up on the concerns before the resident's discharge.
A facility failed to ensure timely and accurate laboratory services for a resident with a potential UTI. Despite physician orders for a urinalysis and culture/sensitivity test, the results were not documented or followed up on, leading to the resident's hospital admission. The lapse was due to a missing order and lack of communication between the facility and the laboratory.
Failure to Protect Cognitively Impaired Residents From Sexual Abuse by a Known Wanderer
Penalty
Summary
The deficiency involves the facility’s failure to protect cognitively impaired residents from sexual abuse by another resident with known wandering and sexually focused behaviors. One resident with Parkinson’s disease and dementia, who had a BIMS score of 5 and a court-appointed guardian due to legal incapacity, had multiple documented episodes of wandering into other residents’ rooms, entering roommates’ space, and looking for his spouse, which upset other residents. Nursing notes over several months described this resident stumbling into another resident’s room, being threatened by another resident to leave, flooding a bathroom, entering a roommate’s space, and urinating on the floor. Staff also documented that this resident grabbed a nurse’s breast multiple times while laughing and yelling, hit a nurse on the rear end, made sexual remarks to female staff, and tried to get into bed with a neighboring resident while that resident attempted to push him away by shaking and pulling the blanket. Despite these repeated behaviors, the facility did not implement effective care plan interventions for wandering or sexually focused behaviors until shortly before the sexual abuse incident. The care plan did not address these behaviors from admission through multiple documented episodes of room entry and inappropriate sexual contact with staff and attempts to get into bed with another resident. The Administrator later stated that, after one incident, the interdisciplinary team decided to move the resident to another unit, which was identified as the unit where the majority of the facility’s most vulnerable residents with Alzheimer’s disease and dementia resided. The Administrator also stated they believed the resident’s wandering was not repetitive or primarily at night and that the resident was easily redirectable, and acknowledged relying on staff reports rather than reviewing the progress notes that documented multiple wandering incidents. The sexual abuse incident occurred when a CNA, during rounds, turned on the light in a female resident’s room and observed the male resident in bed with her, with his hand down the front of her brief. The female resident had dementia, anxiety, adult failure to thrive, severely impaired cognitive skills for daily decision making, and a court-appointed guardian, and was non-verbal and unable to respond during the post-incident assessment. Camera footage showed that no staff were stationed outside the male resident’s room as care-planned, that he left his room in a wheelchair, looked up and down the hallway, and entered the female resident’s room, remaining there for over an hour before being discovered. The CNA initially left both residents in the bed together while going to get assistance, and neither the CNA nor the LPN who responded used translation tools they typically used to communicate with the male resident, who had a language barrier, to obtain his account of the incident. The female resident’s guardian and spouse later reported they were told only that a man had been found in bed with her and were not informed that his hand had been down her brief.
Failure to Provide Timely Assessment and Intervention for Suspected Stroke
Penalty
Summary
A deficiency occurred when the facility failed to provide timely and ongoing assessment and intervention for a resident who experienced a change in condition suggestive of a stroke. The resident, with a history of transient ischemic attack (TIA), cerebral infarction, encephalopathy, and hypertension, reported symptoms including tingling in the left arm and inability to grasp with the left hand. The nurse documented these symptoms and notified the nurse practitioner (NP), who assessed the resident but did not identify significant changes or initiate further evaluation beyond recommending increased blood pressure monitoring. There was no evidence that the recommended monitoring was implemented or that the resident was reassessed following the initial change in condition. The resident's family reported concerns to the facility about the resident experiencing stroke-like symptoms and missing scheduled neurology appointments. Despite these reports and the resident's new onset of left-sided weakness, the facility did not send the resident for further evaluation or to the hospital, as confirmed by the Director of Nursing (DON), who stated that the expectation was to send residents out immediately for new stroke symptoms. The DON also confirmed that the facility lacked a stroke protocol or policy and that no follow-up was conducted on the resident's change in condition. The therapy department identified a significant change in the resident's functional ability the day after the initial symptoms, but there was still no reassessment or intervention documented. The resident ultimately missed two neurology appointments before being seen by a neurologist, who then sent the resident to the hospital for evaluation of a suspected stroke. Hospital records indicated a new chronic lacunar infarct on imaging. The facility failed to provide appropriate and timely care in response to the resident's change in condition, as well as to ensure attendance at necessary medical appointments.
Failure to Ensure Timely Wound Care and Specialist Follow-Up
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely medical appointments and debridement treatments for a resident with a history of gangrene and recent toe amputation, resulting in the worsening of a wound and subsequent hospitalization. The resident, who spoke Korean and had a high cognitive status, was scheduled for follow-up wound care and debridement but was sent to the wrong office for a critical appointment. This error led to a delay of one week before the resident could be seen by the appropriate wound surgeon, during which time the wound deteriorated, ultimately requiring further surgical intervention, including debridement and amputation of an additional toe. The clinical record review revealed that the resident had multiple orders and recommendations for wound care, including specific dressing changes, offloading interventions, and follow-up appointments with wound care specialists and podiatry. Despite these orders, documentation showed missed appointments, lack of timely follow-up, and a failure to implement recommended treatments such as vancomycin, which was noted in progress notes but never ordered or administered. Additionally, the resident was noted to be performing self-care on the wound, which was identified as delaying healing, and there was insufficient use of translation services to address the resident's language barrier, despite the availability of such resources. Interviews with facility staff, including wound nurses, the DON, and the unit clerk, confirmed lapses in communication, scheduling, and follow-up. The unit clerk acknowledged sending the resident to the wrong location, and both wound nurses were unclear about the specifics of the resident's care and did not utilize available translation services. The DON was aware of the language barrier and the resident's self-care but did not ensure the use of interpreter services. Facility policies required weekly evaluation of skin alterations and prompt response to changes in condition, but these were not consistently followed, contributing to the resident's decline and need for hospitalization.
Failure to Provide Supervision During Resident Transportation
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, convulsions, and blindness in one eye, and who was assessed as having moderately impaired cognition and lacking capacity to make reasoned medical decisions, was sent unaccompanied to multiple medical appointments. The resident's clinical record indicated a need for 24-hour care and supervision, and a physician's statement confirmed the resident's inability to provide informed consent or medical history. Despite these documented needs, the resident was transported alone to appointments, and on at least one occasion was left in the lobby of a doctor's office without a caretaker from the facility. Interviews with facility staff revealed inconsistent practices and a lack of clear procedures regarding which residents required staff accompaniment to appointments. The unit clerk stated that, until recently, staff did not accompany residents, and decisions about competency were made informally. The DON acknowledged that the resident should not have been allowed to leave the facility alone, and the administrator recognized the concern regarding the resident's care plan for 24-hour supervision not being followed during transportation to appointments.
Failure to Identify and Respond to Change in Condition and Inadequate Physician Notification
Penalty
Summary
The facility failed to identify and appropriately respond to significant changes in condition for two residents, resulting in serious negative outcomes. For one resident with a history of urinary retention and recent hospitalization, there was a delay in scheduling a required urology follow-up, despite provider orders for timely consultation. The resident exhibited symptoms such as hematuria and pain with urination, and was started on antibiotics for a urinary tract infection (UTI). However, the antibiotic prescribed was not effective against the identified organism, as shown by culture and sensitivity results, yet the ineffective medication continued to be administered. Staff did not document or address additional symptoms such as sore throat, poor oral intake, and mental status changes, and failed to recognize or act upon a significant decline in the resident's condition, including not eating for two days and exhibiting confusion and weakness. The resident was only sent to the hospital after family intervention, where they were diagnosed with UTI, pneumonia, sepsis, and subsequently died from septic shock secondary to UTI and pneumonia. For another resident admitted with a femur fracture, pulmonary hypertension, and heart failure, the facility did not adequately monitor or respond to changes in vital signs and mental status. The resident experienced episodes of low blood pressure, bradycardia, and hypoglycemia, with documentation of lethargy and delayed responses. Despite these changes, there was no documentation that the physician was notified. When the resident's family expressed concern about cardiac issues and requested discharge against medical advice, the facility delayed implementing a STAT EKG order and did not complete the test before the resident was transferred to the hospital for respiratory distress. There was also a lack of documentation regarding the assessment and follow-up of the resident's cardiac and respiratory symptoms prior to transfer. Facility policy required staff to monitor and evaluate residents for changes in condition and to notify the physician team for direction when such changes were identified. In both cases, the facility failed to follow this policy, resulting in delayed recognition and treatment of acute medical issues, lack of appropriate physician notification, and insufficient documentation and follow-up of significant clinical changes.
Failure to Identify and Respond to Change in Condition, Medication Administration, and Documentation Deficiencies
Penalty
Summary
Facility staff failed to ensure timely identification, assessment, and reporting of a resident's change in condition, resulting in multiple hospitalizations. The resident, who had a history of fracture, repeated falls, severe malnutrition, dysphagia, and weight loss, exhibited ongoing symptoms such as poor appetite, gagging, and dry heaving. Despite family concerns and reports of aspiration and emesis, staff did not perform or document comprehensive assessments or obtain vital signs prior to significant events, including hospital transfers. Documentation revealed that staff relied on secondhand information rather than direct assessment, and there was no evidence of timely physician notification or accurate evaluation of the resident's status during these episodes. The facility also failed to follow professional nursing standards for medication administration and monitoring. Blood pressure readings were not consistently obtained before administering antihypertensive medications, and there were instances where medications were held or given without appropriate clinical justification or documentation. Additionally, the facility did not implement or document physician orders for supplemental oxygen and intravenous therapy as required. Oxygen was administered without a physician order, and there was no documentation explaining the rationale, timing, or physician notification regarding changes in oxygen delivery or the resident's elevated heart rate. Nursing skilled notes were incomplete or inaccurate, with missing assessments on key dates and discrepancies between documented care and the resident's actual needs. Orders for IV fluids were not carried out, and abnormal vital signs, such as critically low blood pressure, were not reported to the physician. The lack of timely transfer to a higher level of care, incomplete documentation, and failure to follow facility policies contributed to the resident's repeated hospitalizations and ultimately, the resident's death. Interviews with facility leadership confirmed gaps in assessment, documentation, and adherence to policy.
Plan Of Correction
F684 - Quality of Care It is the practice of the facility to ensure that quality care is provided following the fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Element 1: Resident R402 no longer resides in the facility. Element 2: Residents residing in the facility who have a change in condition have the potential to be affected by the cited practice. The facility has completed audits and reviews of current residents pertaining to any of the cited practices listed below. An audit was conducted to ensure that residents with a change of condition have appropriate evaluation, monitoring, documentation, and physician notification. An audit was conducted on residents who have blood pressure medications to ensure their vital signs were obtained and orders followed as written. A full house sweep was conducted of resident rooms for oxygen and IV equipment and was reconciled with resident active orders for oxygen and IV medications. An audit of residents recently transferred to acute care since the date of survey exit (4/10/2025) was conducted to ensure that acute care transfer was completed in a timely manner in accordance with the residents' needs. If any of the above noted areas were found to be out of compliance, they were corrected immediately with all necessary parties notified. Element 3: A QAPI meeting was held by the interdisciplinary team who reviewed the change of condition policy, medication pass policy, physician orders policy, and the resident transfer policy, to which all were deemed appropriate for use. Facility nurses will be reeducated on the policies with a focus on changes in condition and completion of documentation of the change in condition. Element 4: The DON/Designee will audit for resident changes of condition twice a week for 4 weeks, then monthly for 3 months. Audits will include but are not limited to timely identification, accurate assessment, monitoring, and documentation of the resident's change in condition, documentation and implementation of physician orders, and timely transfers to a higher level of care when necessary. Residents will be discussed within the morning IDT meetings Monday-Friday. The results of the audits will be reviewed during the monthly QAPI meeting. Any areas found to be out of compliance will be corrected immediately with physician and family notifications completed as appropriate. Element 5: The director of nursing is responsible for ultimate compliance. Compliance date of May 6, 2025.
Failure to Timely Assess, Monitor, and Intervene for Severe Weight Loss and Malnutrition
Penalty
Summary
A resident with a history of severe protein-calorie malnutrition, dysphagia, and abnormal weight loss was admitted to the facility following a hospital stay. Upon admission, the resident's weight was recorded as the same as the hospital discharge weight, and the initial nutrition assessment noted a significant weight loss of 30 pounds over the prior three months. Despite this, the facility failed to identify or address a further weight loss of 4.29 pounds within the first week of admission, and no interventions were implemented to prevent additional weight loss for more than two weeks. The resident continued to experience poor appetite, nausea, and difficulty tolerating the prescribed diet, but interventions such as medication adjustments and dietary supplements were delayed or not implemented in a timely manner. Communication and coordination among the facility's interdisciplinary team were lacking. Requests for a gastroenterology (GI) referral for possible PEG tube placement were not followed up promptly, and there was no documentation of timely notification to the physician or action taken regarding the resident's and family's expressed wishes for a feeding tube. The registered dieticians were unaware of the resident's request for a PEG tube and did not document or address the ongoing nutritional concerns. Additionally, the facility failed to consistently monitor the resident's intake, did not obtain a new weight upon readmission from the hospital, and did not ensure that ordered dietary supplements were administered as documented in the medical record. Throughout the resident's stay, there was a breakdown in communication and oversight, with the registered dieticians and nursing staff failing to collaborate effectively or escalate concerns to administration. The resident experienced a severe weight loss of 13.27% within two months, was hospitalized twice for acute changes in condition related to poor intake and dehydration, and ultimately died with severe calorie malnutrition listed as a cause of death. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's nutritional status, interventions, and care planning, as well as failures to follow facility policy on monitoring and addressing nutritional risk.
Plan Of Correction
F692 Nutrition/Hydration Status Maintenance It is the practice of the facility to ensure that resident maintains acceptable parameters of nutritional status such as usual body weight or desirable body weight range and electrolyte balance, unless the residents' clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Element 1: Resident 402 no longer resides in the facility. Element 2: Residents who live in the facility can be affected by the deficient practice. An audit was conducted for residents with recommendations for Gastrointestinal referrals to ensure that they have a physician order for the consult and documentation that an appointment for the consult was scheduled with the Gastrointestinal specialist. Current residents in the facility had their weights reviewed to be sure that the most recent and accurate weights were reported to the Dietitian. An audit was completed by the Dietitian of residents with significant weight loss to ensure physician notification was documented and interventions are in place to address weight loss. Current residents admitted within the last 30 days will be reviewed to ensure admission weights were obtained and recorded in their medical records. Any resident admitted within the last 30 days who does not have a weight recorded in the medical record will be weighed and documented in the medical record. Newly admitted residents will be reviewed by the dietitian to ensure weekly weights are completed and documented for 4 weeks and then as directed by the dietician. The IDT Team will have a nutritional at-risk meeting weekly to review residents at nutritional risk, residents with significant weight loss, and residents with gastrointestinal referrals, to ensure physician notification has been completed and documented, and appropriate nutritional interventions are in place. Element 3: The interdisciplinary team reviewed the Consultations policy and deemed it appropriate. The facility unit clerks and nurse managers were educated on the Consultations policy. The interdisciplinary team reviewed the weight policy and deemed it appropriate for use. The nursing staff and Dieticians were educated on the policy. The interdisciplinary team reviewed the Monitoring Adequate Nutrition and Hydration Status policy and deemed it appropriate for use. The dietitians were educated on the policy. Element 4: The director of nursing/designee will audit residents with recommendations for gastrointestinal referrals to ensure physician orders and appointments are in place weekly for 4 weeks and then monthly for 3 months. The dietitian will audit newly admitted residents to ensure weights are obtained upon admission and weekly for 3 additional weeks and that current residents' ordered weights/reweights are completed and documented. The administrator/designee will audit residents with significant weight loss to ensure physician notification and nutritional interventions were implemented weekly for 4 weeks then monthly for 3 months. The results will be reviewed monthly in QAPI for 3 months and then PRN if no trends are noted. Element 5: The administrator/designee holds the ultimate responsibility of compliance: date of compliance May 6, 2025.
Failure to Follow Two-Person Assist Care Plan Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of a lumbar vertebra fracture and recent acute distal tibia fracture did not receive care according to their established plan, which required two-person assistance for bed mobility, toileting, and transfers. On the date of the incident, an agency CNA provided incontinence care to the resident alone, despite the care plan specifying the need for two staff members. During this care, the resident's right leg came off the mattress and made contact with the floor, which the resident reported caused pain and was followed by a new diagnosis of a distal tibia fracture. The resident, who was cognitively intact and dependent on staff for mobility, described that aides often lifted the pad underneath them to turn or move them, and on this occasion, the CNA moved too quickly, resulting in the leg slipping off the bed. The CNA involved stated that they were not informed of the two-person assist requirement and that it was their first time working at the facility. The facility's documentation and investigation revealed that only one staff statement was obtained, and there was no evidence of staff education or additional interviews with other staff or residents regarding the incident. The facility's own investigation and interviews with the Administrator and DON confirmed that the resident's care plan had not changed before or after the incident and that the resident always required two-person assistance for safety. The lack of adherence to the care plan and insufficient communication to agency staff about resident-specific care needs directly led to the resident sustaining a serious injury during routine care.
Plan Of Correction
F689 Free of Accident Hazards/Supervision/Devices It is the practice of the facility to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Element 1: Resident 406 remains in the facility and continues to receive supportive visits for psych services. The plan of care was updated. Element 2: Residents residing in the facility requiring two persons assist for bed mobility are at risk. An audit was completed by the DON/designee of all residents requiring 2 persons assist with bed mobility to ensure their Kardex and care plan were appropriate to ensure adequate support to prevent accidents. Element 3: The interdisciplinary team reviewed the ADL policy and deemed it appropriate for use as written. Licensed nurses and nursing assistants (to include agency staff) will be educated on the ADL policy with emphasis on following Kardex/Care plan when providing assistance with bed mobility and ADL care. In-services will be ongoing as needed. Element 4: The administrator/designee will conduct random audits for residents requiring 2 people to assist with bed mobility to ensure the plan of care was followed weekly for 4 weeks then monthly for three months. Element 5: The administrator/designee is responsible for compliance: date of compliance May 6, 2025.
Failure to Accurately Document and Implement DNR Order
Penalty
Summary
A deficiency was identified when the facility failed to ensure consistent implementation and documentation of a Do Not Resuscitate (DNR) order for a resident with dementia and a malignant neoplasm of the prostate. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 12, had a DNR order signed by both the resident and their physician. However, the electronic medical record (EMR) demographic page incorrectly listed the resident as "Full code," meaning cardiopulmonary resuscitation (CPR) would be performed in the event of cardiac arrest. During interviews, both a nurse and a social worker reviewed the resident's EMR and initially reported the resident as "Full code." It was only after further review that the social worker discovered the signed DNR order in the record and acknowledged the discrepancy. The social worker was unaware of how the error occurred and indicated the need for correction to reflect the resident's actual wishes as documented in the DNR order. Facility policy requires that a fully executed DNR form be uploaded into the resident's electronic health record and that the physician's order for DNR be entered so the code status is accurately displayed in the chart header and face sheet. In this case, despite the presence of a valid DNR order, the resident's code status was not accurately reflected in the EMR, leading to confusion among staff regarding the resident's end-of-life care preferences.
Plan Of Correction
578 Request/Refuse/Discontinue treatment; Formulate Adv Dir It is the practice of the facility to ensure the resident right to request, refuse and/or discontinue treatment, to participate in or refuse to participate in experimental research and to formulate an advance directive. Element 1 Resident 408 remains in the facility and has been unharmed by the deficient practice. The resident's code status order has been corrected to DNR (do not resuscitate). Element 2 Residents residing in the facility who have signed a DNR are at risk. An audit was completed by the DON/designee of all residents with a signed DNR to ensure their physician order and demographics page match. The plan of care has been reviewed and updated by the interdisciplinary team. Element 3 The interdisciplinary team reviewed the advanced directive policy and deemed it appropriate for use as written. The licensed nursing staff and social work staff were educated on the policy. Element 4 The administrator/designee will audit all new admits/readmits to ensure appropriate advance directives orders and documentation is in place weekly x4 and monthly x3. Element 5 The administrator/designee holds the ultimate responsibility of compliance: date of compliance May 6, 2025.
Failure to Protect Resident from Physical Abuse by Staff Member
Penalty
Summary
A facility failed to protect a resident's right to be free from physical abuse by a staff member. The incident involved a resident with diagnoses including Parkinsonism, dysphagia, and cognitive communication deficit, who required assistance with most activities of daily living and had an intact mental status as indicated by a BIMS score of 14. The resident reported that during the early morning hours, while receiving incontinence care from an assigned nurse, she accidentally kicked the nurse out of fear of falling. In response, the nurse allegedly hit the resident on the left upper arm and told her she would have to wait for the day shift to finish her care. The facility's investigation included interviews with both the resident and the nurse involved. The resident consistently reported the incident, stating she felt safe in the facility otherwise and requested not to have the same nurse assigned to her in the future. The nurse denied the allegations, claiming she did not provide any ADL care to the resident during her shift and only interacted with her for medication administration. The nurse also stated the resident was confused and denied any physical contact or awareness of abuse during her shift. Despite the nurse's denial, the facility substantiated the allegation based on the resident's consistent account, cognitive status, and lack of prior false allegations. The facility's documentation indicated that the nurse had violated work rules related to confirmed verbal, physical, or emotional abuse, rudeness, and negligence toward a resident. The nurse continued to work in the facility after the incident, and the disciplinary action document reflected the substantiated abuse and neglect.
Plan Of Correction
F600 Free from Abuse and Neglect It is the intent of the facility to ensure that all alleged violations are thoroughly investigated to prevent further potential abuse. Element 1: Resident 404 does not reside within the facility. Nurse M is no longer working at the facility. Facility staff were re-educated on Abuse Policy. Element 2: All residents residing in the facility can be affected by the cited practice. Residents with BIMS score of 12 or higher have been interviewed to identify concerns with abuse. Potential allegations identified will be reviewed through the abuse prevention process. Residents with BIMS score of 11 or lower will be assessed for signs and symptoms of abuse. Potential allegations identified will be reviewed through the abuse prevention process. Element 3: The interdisciplinary team reviewed the abuse policy and deemed it appropriate for use as written. The facility staff were educated on the abuse policy; in addition, the facility managers were educated on disciplinary actions and the administrator and DON educated with an emphasis on the reporting within the 2-hour window and what constitutes abuse. The facility staff will be in-serviced on types of abuse at each monthly in-service for the next 3 months to provide additional education. Element 4: The IDT will randomly interview residents and staff regarding allegations of abuse weekly for 4 weeks then monthly for 3 months. Any allegations of abuse will be immediately reported to the administrator for investigation and reporting. The administrator/designee will bring allegations of abuse investigations to the QAPI meeting to ensure compliance. Element 5: The administrator/designee holds the ultimate responsibility of compliance: date of compliance May 6, 2025.
Failure to Timely Report Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of abuse involving a resident who sustained a fracture of the tibia and fibula while receiving care from an agency CNA. The incident took place during a brief change, when the resident's right leg came off the mattress and hit the floor, as described by the resident. The resident reported pain and fear following the incident, but did not immediately notify the nurse due to concerns about the CNA's reaction. The resident later informed a nurse the next day, and subsequently reported increased pain to the Nurse Manager several days later. The clinical record indicated that the resident had a history of orthopedic issues, including a previous lumbar vertebra fracture and was dependent on staff for bed mobility and transfers, requiring two-person assistance and a mechanical lift. Despite the resident's complaints of pain and the change in condition, the Nurse Manager was not notified until several days after the incident, and the Administrator (Abuse Coordinator) was not informed until after the x-ray confirmed the fracture. The facility's own documentation confirmed that the resident's complaints were known to nursing staff prior to the Administrator being notified. The facility's policy required immediate reporting of all allegations of abuse, neglect, or injuries of unknown source to the Administrator and State Survey Agency, but this was not followed. The delay in reporting was acknowledged by facility leadership during interviews, with the Administrator noting that the Nurse Manager should have reported the concern when first made aware. The failure to report the incident in a timely manner constituted noncompliance with federal requirements for reporting alleged violations.
Plan Of Correction
F609 Reporting of Alleged Violations It is the practice of the facility to ensure that all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. If the events do not involve abuse and do not result in bodily injury, reporting is required not later than 24 hours to the administrator and other officials in accordance with state law through established procedures. Element 1: Resident 406 remains in the facility and continues to receive supportive visits for psych services. The plan of care was updated, and she. The contracted CNA involved in the incident no longer works at the facility. All residents residing in the facility can be affected by this cited practice. Residents with BIMS scores of 12 or higher have been interviewed to identify concerns with abuse. Potential allegations identified will be reviewed through the abuse prevention process. Residents with BIMS scores of 11 or lower will also be assessed for signs and symptoms of abuse. Potential allegations identified will be reviewed through the abuse prevention process. Element 2: The interdisciplinary team reviewed the abuse policy and deemed it appropriate for use as written. The facility staff were educated on the abuse policy; in addition, the administrator and DON educated staff with an emphasis on the reporting within the 2-hour window and what constitutes abuse. The facility staff will be in-serviced on types of abuse at each monthly in-service for the next 3 months to provide additional education. Element 3: The IDT will randomly interview residents and staff regarding allegations of abuse weekly for 4 weeks, then monthly for 3 months. Any allegations of abuse will be immediately reported to the administrator for investigation and reporting. The administrator/designee will bring allegations of abuse investigations to the QAPI meeting to ensure compliance with the abuse process, including timely reporting and investigation. Element 4: The administrator/designee is responsible for compliance: date of compliance May 6, 2025.
Failure to Investigate Abuse Allegations and Prevent Further Resident Exposure
Penalty
Summary
The facility failed to thoroughly investigate an initial injury of unknown origin and an allegation of mistreatment for one resident, as well as failed to prevent further access between a resident and an employee with confirmed abuse findings. Specifically, the facility did not complete a comprehensive investigation into the circumstances surrounding the injury and mistreatment, as required by their abuse prevention policy. The policy mandates timely, thorough, and objective investigations, including identifying and interviewing all involved persons, such as the alleged victim, perpetrator, witnesses, and others with relevant knowledge, and providing complete documentation of the investigation. Additionally, the facility did not ensure the protection of a resident by allowing continued access to an employee who had confirmed abuse findings, contrary to the policy that requires immediate removal of the alleged perpetrator from the facility and schedule pending the outcome of the investigation. These failures were identified during the review of two specific intakes and involved at least two residents, one of whom had an injury of unknown origin and another who was exposed to an employee with a history of abuse.
Plan Of Correction
F610 Investigate/Prevent/Correct Alleged Violation It is the practice of the facility, in response to allegations of abuse, neglect, exploitation or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident and if the alleged violation is verified, appropriate corrective action must be taken. Element 1: Resident 406 remains in the facility and continues to receive supportive visits for psych services. The plan of care was updated, and the contracted CNA involved in the incident no longer works at the facility. Element 2: Residents with allegations of abuse have the potential to be affected. Investigation files of those residents with open investigations have been reviewed to validate a thorough investigation was conducted to include implementation of corrective measures to prevent further potential abuse. No additional instances as identified in the citation were identified. Residents with BIMS score of 12 or higher were interviewed to identify concerns with abuse. Potential allegations identified will be reviewed through the abuse prevention process. Residents with BIMS score of 11 or lower will be assessed for signs and symptoms of abuse. Potential allegations identified will be reviewed through the abuse prevention process. Element 3: The interdisciplinary team reviewed the abuse policy and deemed it appropriate for use as written. The facility managers were educated on the abuse policy with an emphasis on completing a full and thorough investigation and on corrective actions to prevent further potential abuse. The Quality Assurance Consultant will in-service Unit Manager and Director of Nursing regarding maintaining all evidence of an investigation. Element 4: Audits on allegations of abuse will be completed weekly by the Administrator/designee to validate a full and thorough investigation was completed, corrective actions were taken to prevent further potential abuse, and that evidence of the investigation is maintained. Results of the audits and interviews will be submitted to the QAPI committee for further review and recommendations. Element 5: The administrator/designee is responsible for compliance: date of compliance May 6, 2025.
Failure to Respond Promptly and Provide Timely ADL Care for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to promptly respond to a dependent resident who was continuously yelling for assistance. Upon observation, three employees, including a CNA, a Nurse Manager, and a Unit Clerk, were seated at the nursing desk and did not respond to the resident's loud calls for help. Other residents and visitors in the area expressed concern about the yelling, but no staff intervened until much later. When the resident's room was entered, the individual was found poorly positioned in bed, with their head and lower extremities nearly off the mattress, and the call light was out of reach. The resident, who was incontinent and unable to reposition themselves, stated they needed to be changed and was found to have a wet brief. The call light was only activated by the surveyor, and staff did not respond until several minutes later. Interviews with staff revealed a lack of timely incontinence care and inadequate attention to the resident's needs. The assigned CNA confirmed that no incontinence care had been provided since the start of the shift, and the Unit Clerk, who was also a CNA, acknowledged the resident was wet and improperly positioned. Staff attributed the resident's yelling to behavioral issues and did not take immediate action, despite care plans indicating the need for call lights to be within reach and regular assistance with toileting and hygiene. Documentation for incontinence care was also incomplete for the day in question. The resident involved had a history of dementia, behavioral disturbances, incontinence, and required moderate assistance with activities of daily living. Care plans included interventions for communication, safety, and elimination needs, but there were no specific interventions for the resident's yelling behavior. Facility policy required repositioning of dependent residents at least every two hours, but this was not observed. The failure to respond promptly, provide timely incontinence care, and ensure proper positioning and access to the call light led to the identified deficiency.
Plan Of Correction
F0677 ADL Care Provided for Dependent Residents It is the practice of the facility to ensure that residents who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Element 1: Resident 410 remains in the facility and has been assisted with repositioning, ADL care, and call light placement at the time of the survey. The plan of care was reviewed and updated. Element 2: Residents who need staff assistance and/or positioning devices for proper positioning have the potential to be affected by the cited practice. An audit of residents requiring staff assistance and/or positioning devices for proper positioning was completed, and their care plans/Kardex were reviewed and updated, if applicable. An audit was completed to ensure call lights were within reach and residents who require staff assistance and/or positioning devices for proper positioning were in place. Element 3: The interdisciplinary team reviewed the "Activities of Daily Living" (ADL's), call light, incontinence care, and repositioning policies and procedures and deemed them appropriate for use as written. The facility licensed nurses and nursing assistants have been educated on the above policies. Element 4: The DON/designee will complete random audits weekly to ensure residents requiring staff assistance and/or positioning devices are properly positioned. The IDT team will complete random audits weekly to ensure call lights are within reach. The IDT team will complete random audits weekly to ensure residents calling out for assistance are responded to. Audits will be completed weekly for 4 weeks, then monthly for 3 months. Any deficient practice will be corrected/updated immediately. The results will also be taken to the QAPI meeting. Element 5: The Administrator is responsible for compliance: date of compliance May 6, 2025.
Failure to Follow Policy for Decision-Making Capacity Assessment and Documentation
Penalty
Summary
Facility staff failed to follow their own policy regarding decision-making capacity assessments for a resident admitted with multiple complex diagnoses, including a right pubis fracture, repeated falls, severe protein-calorie malnutrition, dysphagia, and abnormal weight loss. Concerns were raised by the resident's daughter about the resident's cognition, prompting a discussion with the Social Work Director about the need for a competency evaluation and the possible activation of the resident's Durable Power of Attorney (DPOA). However, this discussion was not documented in the progress notes, and the psychiatric consult to determine capacity was not completed until several weeks later. The evaluation for decision-making capacity was ultimately performed by a contracted physician, who determined the resident lacked capacity due to delirium and encephalopathy. The required facility form, "Physician Statement of Capacity for Medical Treatment and Decisions," was signed by this physician as the second examiner, although they were actually the first to evaluate the resident. The attending physician signed the form the following day, despite the resident having already been transferred to the hospital and not being present in the facility. There was no documentation in the medical record that the attending physician or any other attending clinicians had evaluated the resident for capacity. Additionally, the original capacity form was not found in the resident's medical record, and staff could not provide it when requested. The facility's policy required that two physicians determine incapacity, with thorough examinations and proper documentation uploaded to the resident's chart. These steps were not followed, as only one physician evaluated the resident, and the documentation process was incomplete and inconsistent with facility policy.
Plan Of Correction
F 745 Provision of Medically Related Social Services It is the practice of the facility to ensure that all residents receive medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to follow the policy on capacity decision making for 1 of 4 residents. Element 1 R402 no longer resides at the facility. Element 2 Residents that require a capacity evaluation have the potential to be affected by the cited practice. An audit was completed for residents that have had a capacity evaluation completed to ensure the policy was followed and all appropriate paperwork and documentation is in place. Any deficiencies noted in the audit were immediately corrected. Element 3 The Interdisciplinary Team reviewed the Decision-Making Capacity Policy and deemed it appropriate. All social service staff and the attending physicians have been educated on the policy and procedure with emphasis on ensuring capacity evaluations are being completed timely and with appropriate documentation. Element 4 The Social Service Director, or designee, will complete random audits on residents with a request for a capacity evaluation weekly x 4 weeks then monthly x3. Element 5 The administrator is responsible for compliance with a compliance date of May 6th, 2025.
Failure to Conduct Thorough Investigation After Resident Injury
Penalty
Summary
A resident with a history of lumbar vertebra fracture and requiring two-person assistance with bed mobility sustained a distal tibia and fibula fracture of unknown origin while receiving care from an agency CNA. The resident reported that the aide moved them too quickly during a brief change, causing their right leg to come off the mattress and hit the floor. The resident did not immediately report the incident to nursing staff due to fear, but later informed a nurse manager after experiencing increased pain. The clinical record indicated the resident was alert, cognitively intact, and had ongoing mobility and incontinence needs. The facility's investigation into the incident was incomplete. Only one witness statement was obtained, from the agency CNA involved, who denied the resident's leg hit the floor and stated the resident was already complaining of pain. There was no documentation of interviews with other staff or residents, and no evidence that all relevant parties were questioned. The investigation documents provided to the State Agency and reviewed during the survey were the same, lacking additional statements or supporting evidence. During interviews with facility leadership, it was confirmed that the investigation did not include comprehensive interviews with nursing staff or like-residents, and there was no documentation of education or disciplinary action for staff involved. The administrator acknowledged that the aide did not follow the plan of care, which required two-person assistance, and that the investigation was incomplete. No further documentation or follow-up was provided by the end of the survey.
Failure to Remove Staff from Resident Care Following Substantiated Abuse Allegation
Penalty
Summary
A resident with diagnoses including Parkinsonism, dysphagia, and cognitive communication deficit, who was cognitively intact according to a BIMS score of 14, alleged that during the midnight shift, a nurse physically abused her while providing incontinence care. The resident reported that she accidentally kicked the nurse out of fear of falling, after which the nurse hit her on the left upper arm and told her she would have to wait for the day shift to finish her care. The resident expressed feeling safe in the facility overall but requested not to have the same nurse assigned to her in the future. The facility conducted an investigation into the incident, interviewing both the resident and the nurse involved. The nurse denied the allegations, stating she did not provide any ADL care to the resident and only interacted with her during medication administration, further claiming the resident was confused. Despite this, the facility substantiated the allegation based on the resident's consistent account, cognitive status, and lack of prior false allegations. The facility's documentation indicated that the nurse received a final written warning for confirmed verbal, physical, or emotional abuse, rudeness, and negligence toward the resident. Despite the substantiated abuse allegation and the resident's request, the nurse continued to be assigned to the resident and provided care, including medication administration, on multiple occasions after the incident. The administrator was unaware that the nurse had continued to care for the resident and acknowledged that this was not in line with facility policy, which states that staff involved in abuse allegations should be immediately removed from contact with the resident pending investigation. The facility's own abuse policy requires immediate protective actions to prevent further harm, which were not followed in this case.
Deficiency in Mechanical Lift Maintenance and Availability
Penalty
Summary
The facility failed to provide safe, operational mechanical lifts for three residents, leading to significant issues with resident transfers and mobility. The mechanical lifts were reported to be in disrepair, with batteries frequently not holding a charge, which left residents unable to leave their rooms for activities or exercise. One resident expressed frustration over being unable to maintain their routine of getting up multiple times a week due to the lack of operational lifts. The resident also raised concerns about the potential risks in case of an emergency, such as a fire, where they would need to be evacuated from their bed. Observations and interviews revealed that the facility had issues with the availability and maintenance of mechanical lifts. Certified Nurse Aides reported difficulties in finding charged batteries and operational lifts, which impacted their ability to provide timely care to residents. One resident was observed being transferred with a lift that had medical tape at the anchor, indicating potential safety concerns. Another resident reported discomfort and safety concerns due to the use of an inappropriate lift model for their size, and instances where transfers were conducted with only one staff member instead of the required two. The Maintenance Director acknowledged the issues with the lifts and batteries, citing that the vendor had taken batteries for refurbishment and that routine maintenance had not been conducted due to unpaid bills. The facility's process for reporting maintenance concerns was also found to be inadequate, as staff often did not use the electronic system to log repair needs, leading to delays in addressing issues. During a tour of the facility, it was observed that there were only three operational lifts and no backup batteries available, which further exacerbated the problem of ensuring safe and timely resident transfers.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances from residents participating in the resident council meetings were promptly documented, investigated, tracked, and resolved. During a group meeting, four residents expressed that their concerns raised in the monthly resident council meetings were not addressed or resolved in a timely manner. One resident specifically noted that while concerns were brought up, no resolution was provided. A review of the resident council meeting minutes for September, October, and November 2024 revealed concerns with nursing services. However, the facility's administrator admitted to having no documentation showing that these concerns were addressed or resolved. Additionally, the Activities aide confirmed that while they kept documentation of concerns, there was no grievance resolution form for the nursing services concerns documented in the September meeting minutes.
Deficiencies in Documentation and Medication Administration
Penalty
Summary
The facility failed to ensure services met professional standards of practice for four residents. For one resident, R2, there was a discrepancy in the documentation of their status. Although R2 had been discharged to the hospital on 12/6/24, progress notes were incorrectly documented by an LPN, indicating that R2 was still present in the facility. The LPN responsible for the notes was assigned to a different unit and mistakenly charted on the wrong resident, leading to inaccurate records. Another resident, R45, was observed with a medical measuring cup containing an orange liquid and ointment packets left on their over-bed table. The resident believed the liquid was medication for their bowels. The DON confirmed that medications should not be left at the bedside if a resident refuses them, indicating a lapse in medication administration protocol. For resident R13, a stool sample was mishandled and incorrectly labeled, resulting in a delay in testing for C-Diff as per physician orders. This error led to an extended isolation period for the resident. Additionally, for R308, a urine specimen was sent without proper patient identifiers, rendering it untestable. There was no documentation of communication with the physician regarding the invalid sample, highlighting a failure in the facility's infection control and communication processes.
Discrepancies in Controlled Substance Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of controlled substances for a resident, identified as R258, who was admitted with diagnoses including intraspinal abscess, meningitis, and rheumatoid arthritis. The resident was cognitively intact, as indicated by a perfect score on a Brief Interview for Mental Status assessment. A physician had ordered Hydromorphone 2 mg, to be administered as needed for pain, with a specific instruction to give two tablets every four hours. However, discrepancies were found between the Controlled Drug Receipt/Record/Disposition Form and the Medication Administration Record (MAR) for this medication. On several occasions, tablets were documented as being removed from the resident's supply without corresponding documentation on the MAR indicating that the medication was administered. Specifically, on multiple dates, tablets were removed but not recorded as given, and there were instances of times being altered on the MAR. Additionally, there was no documentation of any medications being wasted. The Director of Nursing was informed of these discrepancies, which involved eight tablets of Hydromorphone that were unaccounted for in terms of administration to the resident.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure medications were stored appropriately and in a safe and sanitary manner, as observed in three of four medication carts and one treatment cart. During an inspection, a coffee cup was found in a medication cart drawer, and several medications, including Lispro Insulin and Brimonidine Tartrate eye drops, were found without open dates, indicating they had been used but not properly labeled. Additionally, another medication cart contained crushed pill debris, and several medications, including a Lantus SoloStar Insulin Pen, a Fluticasone Salmeterol inhaler, and a Spiriva inhaler, were also found undated, confirming they had been opened and used without proper labeling. Furthermore, an unattended and unlocked treatment cart containing various wound care creams and medications was observed, which was later confirmed by the Director of Nursing (DON) to be against the facility's policy. The DON acknowledged that coffee should not be in a medication cart and that all medications should be dated when opened. These observations highlight lapses in the facility's adherence to its medication storage policies, potentially compromising the safety and efficacy of the medications administered to residents.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices related to transmission-based precautions for two residents, R159 and R6, which could potentially lead to the spread of infection. For R159, who was on contact precautions due to a diagnosis of Candida auris, a CNA was observed exiting the resident's room without performing hand hygiene and later re-entering without donning any PPE. The CNA was unaware of the specific precautions required and had not been adequately informed about the differences between transmission-based precautions and enhanced barrier precautions. The Director of Nursing acknowledged the issue and indicated that the Infection Preventionist, who was new to the role, was responsible for infection control. For R6, who was on both enhanced barrier precautions and contact precautions due to an infection requiring IV antibiotics, there was confusion regarding the signage and the precautions to be followed. An unidentified staff member was observed in the resident's room without PPE, and a phlebotomist was seen performing a blood draw without adequate PPE and with a lab cart containing supplies for multiple residents. The Infection Preventionist admitted to being unsure about the correct procedures and deferred to corporate decisions regarding the conflicting signage. The facility's policies and procedures were not adequately followed, as evidenced by the lack of proper PPE use and hand hygiene by staff members. The Infection Preventionist and other staff members were not fully aware of the necessary precautions, leading to inconsistent practices and potential risks of infection transmission. The facility's lab contract required compliance with applicable standards and laws, which was not observed during the survey.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity of its residents, as evidenced by multiple incidents involving residents R259 and R50. R259, who was cognitively intact and required assistance for toileting, reported that a staff member instructed them to urinate in their brief instead of being assisted to the bathroom. Despite informing several staff members, including the Unit Manager, no action was taken to identify the responsible staff member or address the issue. The Director of Nursing was unaware of the incident, indicating a lack of communication and follow-up within the facility. Resident R50, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed multiple times without proper clothing, only wearing a brief or a gown. The facility's staff, including the Social Worker and Certified Nursing Assistant, confirmed that R50 had no personal clothing at the facility. Despite claims that R50 preferred not to wear clothes, there was no documentation or evidence to support this, as R50 had never been provided with clothing during their stay. The facility failed to ensure R50's privacy and dignity by not providing appropriate clothing or ensuring privacy measures were in place. Additionally, during a group meeting, three anonymous residents reported feeling disrespected by the staff, indicating a broader issue of dignity and respect within the facility. These findings highlight systemic issues in the facility's approach to maintaining resident dignity, as evidenced by the lack of appropriate responses to resident concerns and inadequate measures to ensure privacy and respect.
Failure to Ensure Resident Privacy During Medical Procedure
Penalty
Summary
The facility failed to ensure a resident's right to personal privacy during a medical procedure. On December 11, 2024, at 9:18 AM, a resident was observed in their room undergoing a blood draw while the privacy curtain and door were left open, allowing the procedure to be visible from the hallway. This lack of privacy was confirmed by the Unit Manager who was present outside the room. When questioned, the phlebotomist performing the procedure did not provide a response regarding the failure to ensure privacy. The resident involved had been admitted with a diagnosis of Methicillin-susceptible Staphylococcus aureus (MSSA). The facility was unable to provide a policy on privacy during care when requested by the surveyors.
Failure to Document and Communicate Resident Transfer
Penalty
Summary
The facility failed to properly document and communicate the transfer of a resident to the hospital, resulting in a deficiency. The resident, who was cognitively intact and had diagnoses including diabetes, depression, and dementia, was sent to the hospital on 12/6/24. However, the facility did not complete the necessary transfer documentation, such as the hospital transfer form, which should have included critical information like the resident's status, contact information, and recent medical data. Additionally, the resident was still listed as active in the facility's records, and progress notes inaccurately documented the resident as being present in the facility after the transfer date. Interviews with facility staff, including an RN and the DON, revealed a lack of communication and oversight in the discharge process. The RN was unaware of the resident's transfer status and the absence of a transfer form, while the DON acknowledged the oversight and the need for proper documentation. The facility's policy on transfers and discharges, which outlines the required steps and information for a hospital transfer, was not followed, leading to the deficiency identified during the survey.
Failure to Follow Admission Medication Order
Penalty
Summary
The facility failed to ensure an admission medication order was followed for a resident who was admitted requiring nursing care and rehabilitation after a fall resulting in spinal and elbow fractures. The resident had a medical history of hypertension, anxiety, asthma, and muscle weakness, and was cognitively intact with a BIMS score of 14/15. Upon admission, pharmacy recommendations indicated that the resident should not continue on Trelegy Ellipta, an inhaled medication. However, the Director of Nursing (DON) confirmed that the resident continued to receive Trelegy Ellipta, and there was no confirmation that the physician was informed of the pharmacy's recommendation. The facility's policy required new admission orders to be reviewed with the resident's physician for any changes or clarifications, which was not adhered to in this case.
Inadequate Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to adequately assess and implement treatment orders for pressure ulcers for two residents, leading to deficiencies in their care. Resident #38 was admitted for nursing care and rehabilitation following fractures and was cognitively intact. Despite an order for a wound care consult on 10/25/24, a skin assessment on 11/25/24 identified heel breakdown, which was not communicated to the wound care nurse until 12/3/24. During this time, the resident's husband was applying his own treatment to the heels, which was not in line with the prescribed care. Resident #39, who was dependent on staff for most activities of daily living, had a stage III pressure ulcer on the sacral region. The treatment plan for this ulcer was not consistently followed, with missed applications of prescribed treatments on several dates in November 2024. The wound care coordinator and the nurse practitioner had discrepancies in the treatment plan, with the coordinator unaware of changes in the treatment orders. This lack of communication and adherence to the treatment plan resulted in the resident not receiving the appropriate care for their pressure ulcer. The facility's failure to ensure proper communication and implementation of treatment orders for pressure ulcers resulted in inadequate care for both residents. The wound care nurse and other staff did not consistently follow the prescribed treatment plans, leading to a lack of timely and appropriate interventions. This deficiency highlights the need for improved communication and adherence to treatment protocols to prevent further deterioration of residents' conditions.
Failure to Conduct Timely CNA Competency Evaluations
Penalty
Summary
The facility failed to ensure that two Certified Nurse Aides (CNAs), identified as CNA 'L' and CNA 'P', had their skills and competencies evaluated in a timely manner. CNA 'L', hired on April 22, 2011, and CNA 'P', hired on May 14, 2012, both had their most recent skills/competency evaluations completed on July 6, 2023. This indicates that their evaluations were not conducted annually as required. The In-Service Director, who assumed the role in October 2024, acknowledged the lapse and confirmed that the evaluations should be done annually. The facility's policy documentation provided for skills/competencies included only a blank copy of the CENA New Hire and Annual Skills Checklist, further highlighting the deficiency in maintaining up-to-date evaluations.
Failure to Complete Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory diagnostics were completed for two residents, leading to a deficiency in providing timely and quality laboratory services. Resident 47, who had diagnoses including tracheostomy, end-stage renal disease, and cerebral infarction, was ordered to have weekly complete blood count (CBC) and comprehensive metabolic panel (CMP) tests starting from November 18, 2024. However, only one set of results was available with a collection date of December 2, 2024, indicating that the other weekly tests were not conducted as ordered. Similarly, Resident 52, who had severe cognitive impairment and diagnoses including hemiplegia and hemiparesis following a cerebral infarction, had a physician-ordered CBC with differential on November 25, 2024, due to leukocytosis. The medical record did not contain any results for this test. The Director of Nursing (DON) was unaware of the missing lab order for Resident 52 due to an incorrect entry in the electronic medical record, which categorized the order incorrectly. The DON confirmed that the weekly labs for Resident 47 were also not completed, leading to the deficiency identified during the survey.
Failure to Communicate with Hospice Services
Penalty
Summary
The facility failed to ensure proper collaboration with hospice services for a resident who was under hospice care. The resident, who was admitted with multiple medical diagnoses including cerebral infarct, hypertension, atrial fibrillation, right-sided hemiplegia, contractures, sepsis, and urinary retention, was cognitively intact with a BIMS score of 14/15. On a specific date, the resident was observed to be in discomfort, complaining of burning and pain during urination, and a discharge was noted from the penile area. Nursing staff obtained orders to collect a urine sample and remove the catheter. Subsequently, the resident was diagnosed with a urinary tract infection and started on antibiotics. Despite these significant changes in the resident's condition, there was no communication with the hospice service regarding the plan of care, treatment, and interventions for the urinary tract infection. The hospice nurse assigned to the resident was unaware of the concerns related to the Foley catheter and the new clinical issues. The facility's policy required notifying hospice about significant changes in the resident's physical status and clinical complications, but this communication did not occur, resulting in a lack of collaboration between the facility and hospice services.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was readily accessible for all 79 residents and their families or visitors. This deficiency was identified through observation, interview, and record review. On December 10, 2024, the Administrator was asked to provide the daily staff postings for the past three months. Upon review, it was found that several dates in October, November, and December had no daily staff postings available for review. The Administrator explained that the scheduler was responsible for posting the daily staff information, and on weekends, this task was usually handled by the receptionist. However, multiple instances of missing documentation were noted, indicating a failure to consistently post the required staffing information.
Failure to Resolve Resident Grievance on Timely Assistance
Penalty
Summary
The facility failed to adequately follow up and resolve grievances for a resident, identified as R503, who was experiencing issues with timely assistance for bathroom needs. Despite the resident voicing concerns about delayed help, which exacerbated their constipation, the facility did not effectively address the issue. The resident had previously reported the problem, but during an observation, they recounted an incident where a CNA turned off their call light and forgot to assist them, highlighting ongoing neglect in addressing their needs. The facility's grievance process was not properly executed, as evidenced by the incomplete documentation on the Concern Form. Although the Director of Nursing (DON) claimed the issue was resolved by addressing constipation with medication, there was no follow-up on the timeliness of assistance. Additionally, the DON and RN A mentioned informal discussions with staff about call light response, but there was no formal education or documentation to support these efforts. This lack of comprehensive follow-up and documentation contributed to the deficiency in handling the resident's grievance.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Agency as required. The incident involved a resident who was reportedly pushed by a Certified Nursing Assistant (CNA) during a brief change. The resident, who had diagnoses including Morbid Obesity and a Pressure ulcer of the right heel, was dependent on staff assistance for most activities of daily living and had moderately impaired cognition. The incident was reported by the resident's family member, who also notified the police. The police investigated the incident but found no evidence of bruising or sufficient evidence to support the claim. Despite the family notifying the police, the facility did not report the allegation to the State Agency for review, as confirmed by the facility Administrator. The facility's policy requires that all allegations of abuse, neglect, or mistreatment be reported immediately to the Administrator and the State Survey Agency, especially if the allegation involves abuse or results in serious bodily injury. However, a review of the State of Michigan's facility reported incidents system did not show that the allegation had been reported, indicating a failure to comply with the reporting requirements.
Failure to Follow Bed Mobility Plan of Care
Penalty
Summary
The facility failed to ensure that bed mobility was completed according to the plan of care for a resident, leading to a deficiency in providing adequate supervision to prevent accidents. The resident, who was dependent on staff assistance for most activities of daily living and had moderately impaired cognition, required two-person assistance for bed mobility as per their care plan. However, a Certified Nursing Assistant (CNA) did not follow this plan and performed the task alone, which involved rolling the resident during a brief change. A complaint was submitted alleging that the resident was pushed by a facility staff member, and a police report was filed. The investigation revealed that the CNA did not use two staff members as required, resulting in the CNA holding the resident with one hand while changing them with the other. This action was contrary to the resident's care plan, which specified the need for two-person assistance to ensure safety during bed mobility.
Failure to Provide Required Abuse Training to CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) received the required training on abuse policies and procedures before working with residents. This deficiency was identified during a review of a complaint involving a resident who was allegedly pushed by a facility staff member. The incident was reported by the resident's family member, who claimed that the resident was hit on the back by a midnight CNA. A police report was filed, but the officer found no evidence of bruising on the resident. The resident involved in the incident had been admitted to the facility with diagnoses including morbid obesity and a pressure ulcer on the right heel. The resident was dependent on staff assistance for most activities of daily living and had moderately impaired cognition, as indicated by a BIMS score of 12. The facility's investigation into the incident did not provide documentation that the CNA involved had received the necessary training on abuse policies and procedures prior to caring for the resident. The facility's policies require training for new and existing staff on prohibiting, preventing, and identifying abuse, neglect, and exploitation. This training should occur upon hire, annually, and as needed. However, there was no documentation that the CNA had signed off on receiving this training before the incident. The facility administrator acknowledged the lack of training documentation and mentioned plans to improve the process for ensuring agency CNAs are trained before working with residents.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to document follow-up and resolve grievances for a resident, identified as R901, who was reviewed for dignity and respect. On a specific date, a concern was submitted to the State Agency alleging that R901 was not treated with dignity and respect, and their concerns were not being followed up on. During an observation, R901 reported issues with a medication not being administered in a timely manner and stated that despite emailing the Director of Nursing (DON), no follow-up was conducted regarding the resolution of this concern. A review of R901's medical record revealed that they were admitted to the facility with a diagnosis of pain and required assistance with most activities of daily living. R901 had an intact cognition as indicated by a BIMS score of 15. The facility's grievance log did not document the medication concern raised by R901 on a specific date, and several other grievances reported by R901 were found to be incomplete, lacking documentation of follow-up and resolution. The DON acknowledged receiving an email from R901 regarding the medication delay but did not document the concern on a grievance form. The email from R901 detailed a delay in receiving prescribed pain medication due to a nurse's lack of access to the system. The DON's response did not address the medication access/delay concern. The facility's grievance process policy requires prompt efforts to resolve concerns and document actions taken, which was not adhered to in this case.
Failure to Implement Comprehensive Care Plan for Resident with Urinary Conditions
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a complex urinary diagnosis. The resident, who was admitted with a history of recurrent complicated urinary tract infections (UTIs) with multidrug-resistant bacteria, a ureteric stent for hydronephrosis, and chronic kidney disease stage 3, did not have a care plan addressing these conditions. Despite the preadmission documents from the transferring hospital detailing the resident's medical history and ongoing treatment needs, the facility did not create a care plan to manage the resident's urinary tract infection, ureteric stent, hydronephrosis, or chronic kidney disease. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's needs. However, a review of the care plans revealed that no such plan was implemented for the resident's urinary conditions. The Director of Nursing acknowledged that a care plan should have been in place upon admission but did not provide further explanation or documentation by the end of the survey.
Failure to Provide Timely Showers for Resident
Penalty
Summary
The facility failed to ensure timely showers were provided for a resident, identified as R302, who was reviewed for Activities of Daily Living (ADL). The resident was admitted with diagnoses including sciatica, dementia, leukemia, and hearing loss, and was cognitively intact with a BIMS score of 15/15. The resident required assistance with all transfers and had a care plan that included assistance with bathing or showering as needed. However, documentation revealed that the resident did not receive a shower during their stay and only received bed baths starting over three weeks after admission. Complaints were filed with the State Agency alleging inadequate grooming and lack of time for showers by staff. The Director of Nursing (DON) stated that showers or bed baths were typically provided twice a week and should be documented if provided or refused. Despite this protocol, the paper shower sheets indicated that the resident only received bed baths on specific dates, with no documentation of shower refusals or requests for bed baths. The facility's policy emphasized escorting residents to the shower, which was not adhered to in this case.
Failure to Assess and Transfer Resident Promptly
Penalty
Summary
The facility failed to adequately assess a resident, notify the physician of a change in condition, and ensure timely transfer to a higher level of care. The resident, identified as R303, was readmitted with multiple serious diagnoses, including acute respiratory failure and sepsis. Despite the resident's complaints of difficulty breathing and the family's request for hospital transfer, the facility did not perform a complete assessment or notify the physician. On the day of the incident, RN D documented stable vital signs but failed to obtain current respirations, temperature, and pulse oximetry levels, which were crucial given the resident's symptoms. The resident's family had to call 911 to transfer the resident to the hospital, where they were admitted to the intensive care unit with sepsis. Interviews with the family and the resident's roommate confirmed the resident's distress and the family's repeated requests for hospital transfer. The facility's policy required notifying the physician of significant changes in a resident's condition, but this was not done. The Director of Nursing confirmed that a full assessment with current vitals should have been conducted and reported to the physician. Additionally, care plans for the resident's urinary diagnoses were not implemented, further indicating a lapse in the facility's adherence to care protocols.
Failure to Administer Continuous Oxygen as Prescribed
Penalty
Summary
The facility failed to ensure that a resident, identified as R303, received continuous oxygen administration as prescribed by the physician. R303 was readmitted to the facility with a diagnosis of acute respiratory failure with hypoxia and required continuous oxygen delivery via nasal cannula at 3 liters per minute. A family member of R303 reported an incident where they found the resident's oxygen concentrator turned off, and upon informing the nurse, identified as RN A, the nurse was unaware of the situation. RN A acknowledged the incident and mentioned that they believed the resident had been with the beautician that day, but no staff member had informed them that the resident was not receiving their prescribed oxygen. The Director of Nursing (DON) confirmed that there should be no exceptions to providing continuous oxygen to residents prescribed such treatment. An investigation was initiated after the incident was reported. The facility's policy on oxygen administration mandates that RNs and LPNs ensure compliance with physician orders and clinical best practices. However, no further documentation or explanation was provided by the facility by the end of the survey, indicating a lapse in adherence to the policy and a failure to ensure the resident's prescribed care was consistently administered.
Failure to Implement Baseline Care Plan for Resident with Tracheostomy
Penalty
Summary
The facility failed to implement an effective baseline care plan for a resident, identified as R402, who was admitted with chronic respiratory failure, a tracheostomy, and required continuous enteral feeding. Despite the resident's critical condition and need for specific care interventions, the facility did not include an intervention for proper positioning in the care plan, which is crucial for residents receiving enteral feeding and having a tracheostomy. This omission was identified during a review of the resident's care plans, which lacked any mention of positioning strategies to prevent complications associated with tube feeding. The deficiency was highlighted when a nursing note documented that upon a nurse's arrival for a shift, the resident was found unresponsive with a brown substance around the tracheotomy area, and CPR was initiated. The Director of Nursing later confirmed that the resident's code status was full code, and emergency services were called. The facility's standard practice was to implement proper positioning and physician orders upon admission, which was not done for R402, unlike another resident with similar needs who had the intervention implemented on the day of admission.
Failure to Timely Address Change of Condition
Penalty
Summary
The facility failed to address a change of condition in a timely manner for a resident who was experiencing excessive menorrhagia and passing blood clots. The resident's family insisted on sending the resident to the emergency room, and the local police department was contacted to facilitate the transfer. Despite the resident's condition and the family's request, there was a delay of nearly three hours before the resident was transferred to the hospital. During this time, the resident's elevated temperature of 100.5 degrees was not reported to the physician, nor were any interventions administered to address the fever. The Licensed Practical Nurse (LPN) involved did not report the elevated temperature to the physician and did not administer any treatment for it, citing the impending transfer to the hospital as the reason. The LPN stated that they monitored the resident for a period, believing the resident did not want to go to the hospital, until the resident's daughter and the police arrived to facilitate the transfer. The lack of timely action and communication regarding the resident's change of condition and elevated temperature contributed to the deficiency identified in the survey.
Failure to Address and Document Resident's Grievances
Penalty
Summary
The facility failed to accurately document and address the concerns verbalized by a resident (R402) regarding her quality of care. The resident, who had diagnoses including rhabdomyolysis and a urinary tract infection, was reported to have been found on multiple occasions sitting in urine-soaked bed sheets. Despite the resident's son raising concerns about her condition and requesting a urine sample to check for a UTI, the staff did not take the necessary actions to address these concerns. On one occasion, the resident's son found her sitting on soaked bedsheets, which led him to request her discharge from the facility earlier than planned. The facility's grievance policy was not followed, as the concerns were not properly documented or investigated, and no grievance form was completed regarding the specific issue of the resident being found in urine-soaked sheets. Interviews with staff, including the Social Worker (SW B) and Licensed Practical Nurse (LPN G), revealed that the concerns raised by the resident's son were not adequately addressed or documented. The Director of Nursing (DON) acknowledged that the concerns should have been documented on a grievance form but were not. The facility's policy on investigating grievances requires that any verbal or written grievance be given to the Director of Nursing or Designee on duty for proper investigation and follow-up, which did not occur in this case. The resident was subsequently discharged from the facility the day after her son found her in the urine-soaked bed.
Failure to Ensure Physician Follow-Up on Urinary Concerns
Penalty
Summary
The facility failed to ensure consistent physician monitoring and follow-up for a resident with vaginal/urinary concerns. The resident, who was admitted with diagnoses including rhabdomyolysis and a urinary tract infection, had a hospital recommendation for a urine culture to assess antibiotic sensitivity. However, the medical record revealed no results of a urine culture being completed, and there was no documentation of the nurses or physician acknowledging the hospital's recommendation. Despite a physician order to collect urine for urinalysis and culture, the tests were not processed due to a missing order, and the physician did not follow up on the concerns before the resident's discharge. Interviews with the Director of Nursing and the physician confirmed the lack of follow-up and awareness of the hospital's recommendation. The laboratory also indicated that the specimen was rejected due to the absence of an accompanying order, and no notification was generated to recollect the specimen. This resulted in the resident's vaginal concerns not being addressed prior to discharge, highlighting a significant lapse in the facility's care and monitoring processes.
Failure to Ensure Timely Laboratory Services
Penalty
Summary
The facility failed to ensure timely and accurate laboratory services for a resident, resulting in a deficiency. A resident, admitted with diagnoses including rhabdomyolysis and a urinary tract infection, exhibited symptoms of a potential UTI. Despite a nursing note indicating the need to notify the physician about a vaginal odor, there was no follow-up documentation. The next day, a physician ordered a urinalysis and culture/sensitivity test, but the results were not found in the medical record. The facility's Assistant Director of Nursing (ADON) and Director of Nursing (DON) were involved in investigating the missing results, revealing that the laboratory had received the sample but could not process it due to the absence of an accompanying order. The laboratory's standard protocol to notify the facility of the need for a new order was not followed in this case, leading to the deficiency. Interviews with the current ADON and DON confirmed the lapse in communication and follow-up. The ADON stated that the nurse who identified the change in condition should have notified the physician, and the DON confirmed that the laboratory was contacted to resolve the issue. However, the lack of documentation and follow-up on the initial symptoms and the failure to ensure the laboratory test was completed as ordered resulted in the resident being admitted to the hospital with a UTI.
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.
