Optalis Health & Rehabilitation Of Whitehall
Inspection history, citations, penalties and survey trends for this long-term care facility in Whitehall, Michigan.
- Location
- 916 East Lewis Street, Whitehall, Michigan 49461
- CMS Provider Number
- 235206
- Inspections on file
- 31
- Latest survey
- December 26, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Optalis Health & Rehabilitation Of Whitehall during CMS and state inspections, most recent first.
The facility did not consistently follow physician orders for medication administration and monitoring. Several residents did not have required pre-administration assessments, such as blood pressure and heart rate, documented before receiving medications like metoprolol and digoxin. In addition, daily weights were not consistently obtained or reported for a resident with CHF, and prescribed doses of prednisone were missed for another resident without proper documentation.
Two residents experienced delays and lack of resolution after voicing grievances about care and communication, including improper catheter care and insufficient notice of medical appointments. Staff did not consistently document or follow up on these concerns, and residents who could not write were not always assisted in filing grievances, resulting in a failure to address issues as required by facility policy.
Two residents experienced unsafe transfers with a new electronic lift due to lack of staff training, unclear care instructions, and failure to follow manufacturer safety guidelines. One resident hit his head on the lift bar, and staff did not check sling placement or properly position the lift during another transfer. Staff were unaware of required safety steps, and no training had been provided on the new equipment.
A resident with a history of recurrent UTIs and an indwelling urinary catheter did not receive proper infection control measures, including consistent use of PPE by staff and correct handling of the catheter drainage bag. Staff placed the catheter bag above bladder level, causing urine backflow, and failed to follow recommended cleaning procedures. The facility's policy lacked guidance on these critical infection prevention steps, and the resident reported lapses in care and hygiene practices.
The facility did not maintain adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, resulting in insufficient oversight and care.
Three residents received medications outside of prescribed parameters or without proper assessment, including one who was given an incorrect insulin dose and required emergency monitoring. Insulin and antihypertensive medications were administered without documented rationale or provider orders when parameters were not met, and relevant orders were missing from nurse binders.
A resident with a fractured shoulder, dementia, and lack of coordination did not receive the required 1:1 meal assistance as outlined in her care plan and Kardex. Observations showed her meal trays were left out of reach or without help, and documentation did not accurately reflect her needs or intake.
A resident with multiple sclerosis and limited mobility developed a pressure ulcer that was not promptly reported to the provider or DPOA, and required treatments were not consistently completed or documented. The resident was observed in the same position for extended periods despite care plan interventions, and there was a lack of timely communication and documentation regarding the wound and its management.
The facility did not consistently follow physician-ordered wound care protocols or provide adequate interventions to prevent skin breakdown for multiple residents with wounds or at risk for pressure injuries. Treatments such as barrier creams, wound cleansers, and dressings were missed on several occasions, and there was no documentation explaining the omissions.
A resident with complex medical needs did not receive care and services according to provider orders and her preferences. The facility failed to provide a gluten-free diet, did not administer wound care as ordered, neglected to obtain daily weights or follow-up labs, and did not notify the provider of significant weight loss. Additionally, there was a discrepancy in the resident's code status documentation, with staff unaware of the correct DNR status.
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 68 residents. Observations included mold and debris in the Walk-In Cooler, undated hot dogs, residue on kitchen equipment, and ice build-up in the Walk-In Freezer. These issues indicate non-compliance with FDA Food Code requirements, increasing the risk of cross-contamination.
The facility failed to implement an effective infection control program, lacking surveillance and documentation of infections among residents and staff. The abrupt departure of the PDON/ICP left the program without oversight, and no records were available for the months of October to December 2024. Employee absences due to illness were not documented or followed up on, indicating non-compliance with infection control policies.
The facility failed to meet the needs of four residents, including a male with Alzheimer's and a female with vascular dementia, by not ensuring call lights were accessible and not responding promptly to requests for assistance. Residents were left without access to necessary items like blankets and fluids, and staff did not adequately address their expressed needs.
A CNA in a LTC facility was found to have verbally abused multiple residents, using derogatory language and profanity. Witnesses confirmed the CNA's inappropriate behavior, which violated the facility's abuse policies. Despite some residents not recalling the incidents, the facility's investigation substantiated the claims, leading to the CNA's termination.
The facility failed to report suspected abuse in a timely manner, involving verbal and mental abuse by staff towards three residents. The facility's policy required immediate reporting to the Administrator, but delays occurred, with the State Survey Agency being informed a day later. A CNA involved in reporting the incident lacked documentation of education or discipline for the delay.
The facility failed to adhere to professional standards in medication administration, resulting in errors for several residents. Controlled medications were not properly documented, and medications were administered without following physician-ordered parameters. Additionally, a resident received an incorrect dose of an antipsychotic medication due to transcription errors.
The facility failed to provide timely and appropriate care to three residents, resulting in untreated conditions and delayed treatments. A resident experienced significant swelling in the feet that was not documented or assessed, another had a missed order to change tube feed guidelines, and a third experienced a delay in treating a urinary tract infection. These deficiencies were attributed to administrative changes, staff turnover, and delays in lab results.
A facility failed to prevent the misappropriation of controlled substances for three residents. A CNA observed an RN pocketing a narcotic pill meant for a resident, who confirmed not receiving it. The incident was not immediately reported to the State Agency, and the RN continued working before being removed. An audit revealed two more missing narcotics belonging to other residents, found in a bathroom. The facility remained non-compliant with narcotic documentation and storage standards.
The facility failed to use wheelchair footrests for two residents, one with paralysis and another with dementia, leading to potential hazards. A CNA propelled a resident without footrests, and another resident, at high fall risk, self-propelled into obstacles, causing entanglement with another wheelchair.
A facility failed to ensure pharmacy recommendations were documented and communicated to the physician for a resident with multiple diagnoses, including diabetes and hypertension. The pharmacist noted irregularities in the medication regimen review, but the report was missing from the resident's medical record, and the physician was not informed. The Nursing Home Administrator confirmed the absence of documentation during the survey.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for two residents. One resident received Ciprofloxacin without proper documentation or clinical criteria, while another was given an ineffective antibiotic before switching to an appropriate one. The program lacked proper oversight and documentation, resulting in deficiencies in monitoring and tracking antibiotic use.
The facility failed to provide pneumococcal immunizations per CDC recommendations and resident consent for three residents. A resident with pneumonia and two others with pertinent health conditions had no documentation of receiving or being offered the vaccine. The Infection Control Program, managed by two different PDON/ICPs, did not ensure proper immunization practices, as confirmed by the Regional Director of Clinical.
Surveyors found multiple medication carts left unlocked and unattended, with loose pills present and several opened medications, such as insulin pens and eye drops, lacking required date labels. Staff confirmed that carts should be locked and medications properly labeled, in accordance with facility policy and industry standards.
The facility failed to properly assess, monitor, and document pressure injuries for several residents, leading to inadequate care. One resident had a Stage II pressure injury and a deep tissue injury that were not properly documented or treated, with delays in notifying the physician. Another resident experienced delays in treatment and inconsistent evaluations of a pressure injury, with conflicting documentation. Additionally, a resident with quadriplegia had multiple concurrent treatment orders for a sacral wound, leading to missed treatments. The facility also failed to consistently obtain weights for a resident with CHF, as required.
Failure to Follow Physician Orders for Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure that weights were obtained and medications were administered in accordance with physician orders for five residents reviewed for nursing services. For one resident with adrenocortical insufficiency, two doses of prescribed prednisone were not administered as ordered, and there was no documentation of a rationale or provider order for withholding the medication. The DON confirmed the missed doses and lack of documentation. For three residents with congestive heart failure and hypertension, medications such as metoprolol and digoxin were administered without obtaining required pre-administration assessments, including blood pressure and heart rate, as specified in the physician orders. Documentation showed that these assessments were either not performed or not recorded prior to medication administration, and there was no documentation explaining the rationale for administering the medications without the required assessments. Additionally, for one resident with congestive heart failure, daily weights were not consistently obtained as ordered, and significant weight gains that should have triggered provider notification were not acted upon or documented. The DON confirmed that weights were not consistently documented or reported as required by the provider orders.
Failure to Timely Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to resolve grievances in a timely manner for two residents who voiced concerns about their care and communication. One resident, a female with paraplegia, diabetes, and a urinary catheter, reported ongoing issues with staff not using proper personal protective equipment (PPE) during catheter care, improper cleaning of her catheter, and staff refusing to assist her when she experienced pain and issues with her catheter. She stated that she reported these concerns to the Director of Nursing (DON), who documented the issue on a sticky note but did not follow up or provide her with a copy of her grievance. The resident was unable to write due to hand contractures and required staff assistance to document her concerns, which was not consistently provided. Interviews with CNAs confirmed ongoing concerns about infection control and lack of response from the Registered Nurse Unit Manager (RNUM), but no additional grievance forms were found to address these issues. Another resident, a male with a history of stroke and spinal cord disease, expressed frustration with the lack of communication regarding his outside medical appointments. He reported that he was not informed of appointments in advance and was unaware of the facility's grievance process. The resident stated that staff did not offer to help him complete a concern form, despite his difficulty writing. During an interview, the facility's Social Worker acknowledged the concern but did not offer to complete a grievance form, instead stating she would relay the issue to the scheduler. The Appointment Scheduler confirmed attempts to arrange the resident's orthopedic appointment but was unaware of the resident's desire for earlier notification. The Nursing Home Administrator was not aware of the resident's concerns until informed during the survey and noted that staff education on the grievance process was ongoing. The facility's policy required that grievances be documented and responded to promptly, with actions taken to prevent potential violations of residents' rights. However, the investigation found that grievances were not consistently documented, residents were not always assisted in filing grievances when unable to do so themselves, and timely follow-up and resolution were lacking. The absence of proper documentation and response to residents' concerns, particularly regarding infection control and communication about medical appointments, constituted a failure to honor residents' rights to voice grievances without discrimination or reprisal.
Failure to Ensure Safe Transfer Practices with Electronic Lift
Penalty
Summary
The facility failed to ensure safe transfer practices with an electronic lift for two residents who required assistance. One resident expressed discomfort with the new electronic lift, stating it did not fit properly and that he hit his head on the bar during a transfer. The resident's care guide specified the use of a toileting sling and hoyer lift with two staff for transfers, along with cervical precautions, but did not indicate which brand or size of sling should be used. Staff interviews revealed a lack of clarity regarding sling assessments and appropriate equipment selection for the resident, and there was no documentation that the incident of the resident hitting his head had been reported or addressed. During direct observation, staff were seen transferring another resident with the new lift without following manufacturer safety instructions. The bed was in the highest position, and the resident's buttocks did not clear the mattress before being moved. Staff did not check that all sling loops were properly attached before moving the resident, and the lift's legs were not in the fully open position as required for stability. Both staff members involved in the transfer were unaware of the need to check loop placement, ensure the resident cleared the surface before moving, or that the lift legs should be fully open for safety. Further review showed that staff had not received training on the new lift since its purchase, and there was no evidence that management had addressed residents' concerns or reported incidents related to the lift. The instruction manual for the lift provided clear safety requirements that were not followed during observed transfers. The lack of training, unclear care instructions, and failure to follow manufacturer guidelines contributed to unsafe transfer practices and accident hazards for residents requiring lift assistance.
Failure to Implement Proper Infection Control for Catheterized Resident
Penalty
Summary
A deficiency was identified when a resident with a history of recurrent urinary tract infections (UTIs), paraplegia, and an indwelling urinary catheter did not receive proper infection prevention and control measures. The resident's care plan required enhanced barrier precautions, including the use of gowns and gloves during direct care, and specified that the urinary catheter drainage bag should be kept below bladder level to prevent backflow. However, observations revealed that staff did not consistently use personal protective equipment (PPE) such as gloves and gowns when providing care, as reported by the resident herself. The resident expressed concern that this lack of PPE use was contributing to her recurrent UTIs. During direct care, certified nurse aides (CNAs) were observed removing the Foley catheter bag from its privacy bag and placing it on the bed above the resident's bladder level. This action caused urine from the external measuring device to flow back up the catheter tube into the resident's bladder. The CNAs admitted they were unfamiliar with the external measuring device and had not received training on its proper use or the importance of bag placement. Additionally, a soaker pad was found to be wet with urine, and the CNAs stated that the resident did not normally have catheter leakage. A review of the facility's catheter draining bag emptying policy revealed it lacked instructions on keeping the Foley bag below bladder level and on cleaning the emptying device tip with alcohol after use, both of which were included in the hospital's discharge instructions for the resident. The resident also reported that staff did not use alcohol swabs or paper towels when emptying the catheter bag, and that she was not checked or repositioned during the night as required by her care plan.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels were insufficient to address resident care requirements, and there were shifts without a licensed nurse present to oversee care.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to follow professional standards of quality in medication administration for three residents. One resident with diabetes mellitus was given an incorrect dose of insulin after a nurse read the wrong record, resulting in the resident being sent to the emergency room for monitoring due to the risk of hypoglycemia. Another resident with type 2 diabetes mellitus received insulin doses outside of the prescribed blood sugar parameters on multiple occasions, with no documentation of the rationale for administering the medication outside of those parameters or any provider order authorizing such administration. Additionally, this resident was not included on the list of orders with parameters for holding medications in the nurse binder. A third resident with hypertension received Losartan despite blood pressure readings that were outside the parameters set by the provider's order, or without a blood pressure assessment prior to administration. There was no documentation explaining the rationale for administering Losartan outside of the prescribed parameters or any provider order to do so. This resident was also not included on the list of orders with parameters for holding medications in the nurse binder. These findings were based on interviews, record reviews, and review of medication administration records.
Failure to Provide Required Meal Assistance
Penalty
Summary
The facility failed to provide necessary meal assistance to a resident who required 1:1 help with eating due to a fractured right shoulder, dementia, and lack of coordination. On two separate mornings, the resident was observed with her meal tray left out of reach or placed in front of her without assistance, despite care plan and Kardex instructions specifying the need for 1:1 assistance. Documentation inconsistencies were also noted, with staff recording the resident as 'not available' for one meal and indicating partial intake for another, even though the resident reported difficulty eating without help.
Failure to Prevent and Manage Pressure Ulcer and Notify Provider and DPOA
Penalty
Summary
The facility failed to provide care in accordance with professional standards and its own policies to prevent the development and worsening of a pressure injury for a resident with multiple sclerosis and limited mobility. The resident was observed in bed for extended periods, with her position unchanged for several hours, and her heels resting directly on the bed surface despite care plan interventions requiring heel elevation and frequent repositioning. Staff interviews confirmed that the resident was to be repositioned at least every two hours, but observations showed this was not consistently implemented. Documentation review revealed that the resident developed two open sores in the coccyx area, which were not promptly reported to the provider or the resident's DPOA. There was a significant delay in notifying the provider (12 days after initial identification) and the DPOA (18 days after identification) of the pressure injury. Additionally, there was no documentation of new care plan interventions or treatment orders at the time the wounds were first identified, and the DPOA was not informed of subsequent treatment changes in a timely manner. Treatment records showed that ordered wound care was not consistently completed on several dates, and there was a lack of documentation regarding the implementation of new treatments. The facility's own policy required prompt notification of the provider and responsible party, timely implementation of treatments, and regular documentation and monitoring, all of which were not followed in this case. Family interviews further indicated a lack of communication regarding the resident's condition and care, with the DPOA unaware of the wound's status and treatment changes.
Failure to Follow Physician-Ordered Wound Care and Prevent Pressure Injuries
Penalty
Summary
The facility failed to follow physician-ordered wound care and did not provide adequate care to prevent the development of skin breakdown or pressure injuries for six residents reviewed for skin integrity issues. Multiple residents had specific wound care orders, such as the application of zinc oxide, barrier creams, hydrogel, collagen powder, and other treatments at prescribed times and frequencies. However, treatment administration records revealed that these wound care interventions were frequently missed or not completed as ordered. In several cases, there was no documentation in the electronic medical record to account for the missed treatments. Residents affected included individuals with existing wounds or at high risk for skin breakdown, such as those with excoriation, pressure injuries, abrasions, and impaired skin. The missed treatments occurred across various shifts and dates, with some residents not receiving wound care at all during certain scheduled times. The lack of adherence to prescribed wound care regimens and the absence of documentation for missed treatments contributed to the deficiency identified during the survey.
Failure to Follow Provider Orders and Resident Preferences Results in Poor Care
Penalty
Summary
The facility failed to provide care and services in accordance with provider orders, resident preferences, and goals for one resident with multiple complex medical conditions, including congestive heart failure, irritable bowel syndrome, dysphagia, and gluten intolerance. Upon admission, the resident had clear hospital discharge instructions for wound care, a gluten-free diet, daily weights, and follow-up laboratory testing due to a history of hypokalemia and ongoing diuretic therapy. However, the facility did not transcribe or implement these orders accurately. The resident did not receive zinc oxide as ordered for skin excoriation, and the application was not performed three times daily as required. The gluten-free diet was not ordered or provided upon admission, resulting in the resident receiving meals containing gluten, which led to excessive diarrhea and further skin breakdown. Additionally, the facility failed to order or complete the recommended follow-up laboratory tests to monitor electrolyte levels, despite the resident's risk factors and recent history of hypokalemia. Daily weights were not obtained as ordered, and significant weight loss of approximately 23 pounds over six days was not identified or reported to the provider. Documentation in the medical record was incomplete, and there was no evidence that the physician was notified of these significant changes in the resident's condition. There was also a failure to ensure accurate documentation and communication regarding the resident's code status. Although a Do Not Resuscitate (DNR) order was signed and available in the electronic medical record, the active order in the system remained as Full Code, and facility staff were unaware of the discrepancy. These failures resulted in the resident not receiving care and services as ordered and as needed for her medical conditions.
Deficiencies in Kitchen Cleanliness and Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance of food service equipment, as well as to date mark potentially hazardous food items, which could affect 68 residents. During an initial tour of the kitchen, several issues were observed, including mold, mildew, grime, and debris on the shelving and fan compressor grate inside the Walk-In Cooler. Additionally, an undated container of hot dogs was found stored on the shelving. In the cook line area, the can opener blade and holster had food residue and debris, and the commercial blender lid had a yellow/white build-up with black speckles resembling mold or mildew. Further observations revealed ice build-up on the shelving and opened/sealed boxes of food in the Walk-In Freezer, located directly beneath the compressor unit. The Reach-In Cooler units throughout the kitchen were also found to have food residue and debris on the shelving, bottoms, doors, and door openings. These findings indicate a failure to adhere to the 2017 FDA Food Code requirements for equipment cleanliness, food-contact surfaces, and proper food storage, increasing the likelihood of cross-contamination and bacterial harborage.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of surveillance, tracking, and monitoring of infections among residents and staff. During the survey, it was discovered that the facility did not maintain any line lists or documentation of confirmed or suspected infections for the months of October to December 2024. This deficiency was further compounded by the abrupt departure of the Previous Director of Nursing/Infection Control Preventionist (PDON/ICP) S, who had been responsible for the program for the past six weeks. The Regional Director of Clinical (RDC) X confirmed that both PDON/ICP S and the previous PDON/ICP T were responsible for the oversight and maintenance of the Infection Control Program, yet no records were available to demonstrate compliance with the facility's infection control policies. The facility's policy on Infection Prevention and Control-Surveillance, dated July 11, 2018, outlines the requirement for ongoing monitoring and documentation of infections among residents, employees, volunteers, and visitors. However, the review of the 300/400 Unit Scheduling Book revealed employee absences due to illness, with no documentation of the unit they worked in, the residents they interacted with, or any follow-up actions taken to prevent the spread of infection. This lack of documentation and follow-up indicates a failure to adhere to the facility's stated goals of decreasing infection risk and maintaining compliance with state and federal regulations.
Failure to Accommodate Resident Needs
Penalty
Summary
The facility failed to accommodate the needs and preferences of four residents, as observed during a survey. Resident #45, a male with Alzheimer's, lack of coordination, muscle wasting, and a below-the-knee amputation, was repeatedly observed with his call light out of reach, preventing him from requesting assistance. On multiple occasions, he was unable to reach his blanket and expressed feeling cold, yet staff did not adequately address his needs. Similarly, Resident #67, a female with vascular dementia and other conditions, was left shivering in her wheelchair after staff delayed assisting her with dressing, despite her call light being activated. Resident #62, a female with dementia and other health issues, was observed without access to fluids while sitting at the nurses' station and self-propelling in her wheelchair throughout the facility. She expressed thirst, yet no fluids were provided within her reach. Additionally, Resident #7, a male with chronic kidney disease and other serious health conditions, had his call light activated for over an hour without response, leaving him without fresh water. These observations indicate a failure to ensure call lights were accessible and to respond promptly to residents' needs, as outlined in the facility's policy.
Verbal and Mental Abuse by Staff in LTC Facility
Penalty
Summary
The facility failed to protect residents from verbal and mental abuse by staff, specifically involving a Certified Nursing Assistant (CNA) identified as CNA B. The incidents involved five residents, with specific allegations of verbal abuse and derogatory language directed at residents. The facility's investigation revealed that CNA B used inappropriate language, including profanity, in the presence of residents, creating an uncomfortable environment. Witnesses, including other CNAs and staff, corroborated these allegations, noting that CNA B often used profanity and derogatory terms in resident care areas. One resident, identified as R12, was reportedly called 'fat and disgusting' by CNA B, although the resident, who was hard of hearing, did not recall the incident. Another resident, R35, was allegedly called an 'a**hole' by CNA B, and although the resident did not remember the specific incident, they confirmed hearing profanity from CNA B. Additionally, R53 was reportedly subjected to derogatory comments about their hygiene, although the resident did not recall these comments. The facility's investigation substantiated these claims based on witness statements, despite some residents not recalling the incidents. The facility's policies on abuse and neglect clearly define verbal and mental abuse, including the use of disparaging language. Despite these policies, the investigation concluded that CNA B's behavior violated these standards, leading to a hostile environment for both residents and staff. The facility's administration was initially unaware of the extent of the issue until it was reported and investigated, resulting in the termination of CNA B's employment due to the substantiated allegations of abuse.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to develop and implement policies and procedures for timely reporting of suspected abuse, neglect, or theft, as required by section 1150B of the Act. This deficiency involved three residents who were subjected to verbal and/or mental abuse by staff members. The facility's Abuse and Neglect Policy and Procedure, dated 3/24/23, outlined that all allegations and suspicions of abuse must be reported immediately to the Administrator or the Administrator's Designee. However, the facility did not adhere to this policy, resulting in a delay in reporting the incidents to the State Survey Agency. The incident involved a Certified Nursing Assistant (CNA) who failed to report allegations of abuse immediately. On 11/11/24, CNA B was reported to have used inappropriate language towards two residents, calling one an "*sshole" and being rude and disrespectful to another. The report was not made to the Interim Nursing Home Administrator until the following day, and the State Survey Agency was not informed until later that day. The personnel file of CNA C, who reported the incident, lacked documentation of any education or discipline regarding the failure to report the allegations timely, although a Teachable Moment form indicated she was educated on the need to report such allegations immediately.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to administer controlled medications following professional standards of practice, resulting in several medication administration errors. For Resident #5, the administration of HYDROcodone-Acetaminophen was not properly documented, with one dose being illegible and not recorded in the Medication Administration Record. Similarly, Resident #46's records showed discrepancies between the Control Substance Record and the Medication Administration Record, indicating that not all doses were administered as documented. Resident #7 also experienced a similar issue, where the Control Substance Record showed fewer doses of oxyCODONE administered than what was documented in the Medication Administration Record. The facility also failed to ensure medications were administered following physician-ordered parameters. Resident #2 was given Midodrine without proper blood pressure assessments, contrary to the physician's orders to hold the medication if blood pressure was over 120. This resulted in the administration of Midodrine when the resident's blood pressure was above the specified threshold. Additionally, Resident #24 received insulin despite having blood sugar levels below the threshold specified in the physician's orders, indicating a failure to adhere to the prescribed parameters for insulin administration. Furthermore, the facility inaccurately transcribed and ordered a newly admitted resident's antipsychotic medication. Resident #68 was prescribed 100 mg of quetiapine at bedtime, but the facility administered 200 mg, resulting in the resident receiving twice the ordered dose. This error persisted from the time of admission, as reflected in the Electronic Medication Administration Records, and was confirmed by the facility's administrator upon review.
Failure to Provide Timely and Appropriate Care
Penalty
Summary
The facility failed to provide quality care to three residents, resulting in untreated conditions and delayed treatments. Resident #14 experienced significant swelling in the feet, which was not documented, monitored, or assessed despite a noticeable weight increase and previous diagnoses of lymphedema and chronic kidney disease. The care plan required daily skin observations and reporting of changes, but the edema was not reassessed or addressed in subsequent physician assessments. Resident #3 had a missed order to change tube feed guidelines, which was recommended by a registered dietitian due to frequent clogging issues. Despite the recommendation to adjust the feeding rate and flush volume, no follow-up or changes were made to the tube feed orders for nearly a month. The oversight was attributed to administrative changes and staff turnover, leading to the recommendation falling through the cracks. Resident #19 experienced a delay in treating a urinary tract infection. The resident reported symptoms consistent with a UTI, but there was a significant delay between the onset of symptoms and the administration of antibiotics. The facility awaited culture results before starting treatment, and the resident was eventually hospitalized due to the UTI and lethargy. The delay was partly attributed to the time taken for lab results to be returned.
Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to prevent the misappropriation of controlled substances for three residents. An incident occurred where a certified nurse aide observed a registered nurse placing a narcotic pill prescribed to a resident into her pocket. The resident confirmed that he had not received his pain medication. The incident was reported to the interim nursing home administrator, who did not immediately report it to the State Agency or suspend the registered nurse. The registered nurse continued to work an additional shift before being removed from the floor the following morning. An audit of the medication cart used by the registered nurse revealed two additional narcotics were unaccounted for, which belonged to two other residents. These missing narcotics were later found in a medication cup in a bathroom. The facility's policy on abuse and neglect emphasizes providing care in an environment free from misappropriation of property. However, the facility failed to demonstrate substantial compliance with narcotic documentation and storage, remaining out of compliance with professional standards for controlled drug administration and documentation.
Failure to Use Wheelchair Footrests Leads to Hazards
Penalty
Summary
The facility failed to ensure the use of footrests on wheelchairs for two residents, leading to potential accident hazards. Resident #44, a female with left-sided paralysis following a stroke and abnormal posture, was observed being propelled by a Certified Nurse Aide (CNA) down a hallway without footrests on her wheelchair. This lack of footrests could contribute to instability and potential injury during transport. Resident #62, a female with dementia, rheumatoid arthritis, and a high risk for falls, was also observed without footrests on her wheelchair. She was pushed by a CNA and later self-propelled down a hallway, encountering obstacles such as meal service carts. This led to a situation where she leaned forward to move a cart, and subsequently, her wheelchair became entangled with another resident's wheelchair, causing frustration and requiring staff intervention to resolve the situation.
Failure to Document and Communicate Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were received and reviewed by the physician for a resident, leading to a deficiency in the medication regimen review process. The facility's Medication Regimen Review (MRR) Policy and Procedure requires that any irregularities identified by the pharmacist be reported to the attending physician, medical director, and Director of Nursing Services within seven working days. However, for one resident, the pharmacist noted irregularities on the Medication Regimen Review form but did not specify what they were, and the corresponding report was not found in the resident's electronic medical record. The resident in question had multiple diagnoses, including diabetes, hypertension, hyperlipidemia, and paranoid schizophrenia. Despite the pharmacist's indication of irregularities, there was no documentation in the resident's medical record to show that the physician was aware of these recommendations. During interviews, the Nursing Home Administrator acknowledged the absence of the pharmacy report and the lack of evidence that the physician had been informed. The facility was unable to provide any further documentation related to the pharmacy recommendation by the completion of the survey.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, resulting in inappropriate antibiotic utilization for two residents. The previous Director of Nursing/Infection Control Preventionist (PDON/ICP) abruptly ended her employment, leaving the program without proper oversight. The Regional Director of Clinical (RDC) confirmed that the PDON/ICP was responsible for monitoring antibiotic use and ensuring clinical criteria were met, but this was not effectively carried out. For Resident #5, there was no documentation of clinical criteria for the use of Ciprofloxacin, no culture and sensitivity report reviewed, and no provider rationale for the continued use of the antibiotic. This lack of documentation and oversight led to the inappropriate administration of antibiotics without proper justification or evidence of necessity. Resident #45 was initially prescribed Macrobid for a UTI, but a culture and sensitivity report later indicated resistance to this antibiotic. Despite this, Macrobid was administered twice before switching to Ciprofloxacin, which was deemed appropriate by the culture report. The facility's Infection Control Program documentation lacked surveillance and tracking of infections and antibiotic use, further highlighting the deficiency in the antibiotic stewardship program.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to provide pneumococcal immunizations according to CDC recommendations and resident consent for three residents. Resident #18, a female with a history of pneumonia, had no documentation of receiving or being offered the pneumonia vaccine since her admission. Similarly, Resident #4, who was readmitted with pneumonia, lacked documentation of vaccine administration or discussion with her guardian. Resident #56, with lung and heart disease, also had no record of receiving the vaccine or having it discussed with him or his guardian. These deficiencies were identified during a review of the residents' electronic medical records. The facility's Infection Control Program, which was overseen by two different Directors of Nursing/Infection Control Preventionists (PDON/ICP) over a short period, failed to ensure that the necessary immunizations were offered and documented. The Regional Director of Clinical confirmed the absence of historical data for the pneumococcal immunizations for these residents and acknowledged the need to obtain consent and offer the immunizations. The facility's policy on Infection Prevention and Control, dated 2018, emphasized the importance of offering immunizations to decrease the incidence of preventable infectious diseases, but this was not adhered to in these cases.
Unsecured Medication Carts and Improper Medication Labeling
Penalty
Summary
Surveyors observed multiple instances where medication carts were left unlocked and unattended by licensed nursing staff. Specifically, one medication cart was found unlocked and unattended, containing five loose pills in a drawer, and several medications, including Lantus insulin pens and brimonidone eye drops, were not labeled with the date they were opened. Another medication cart was found with eight loose pills in a drawer. Additionally, both medication carts on a particular hall were observed sitting side by side, unlocked and unattended, while a registered nurse was away from the carts. Interviews with staff confirmed that medication carts should be locked at all times when not attended by a nurse, and that loose pills should not be present in the carts. Review of facility policy and industry standards indicated that all drugs and biologicals must be stored in locked compartments and that opened medications should be dated according to manufacturer guidelines. The failure to secure medication carts and properly label opened medications was directly observed and acknowledged by staff.
Deficiencies in Pressure Injury and Wound Care Management
Penalty
Summary
The facility failed to adequately assess, monitor, and document pressure injuries and wounds for several residents, leading to deficiencies in care. For one resident, there was a lack of proper assessment and documentation of pressure injuries, including a Stage II pressure injury to the buttocks and a deep tissue injury to the left foot. The resident was observed multiple times without necessary protective equipment, such as offloading boots and cushions, and there was a delay in notifying the physician and obtaining treatment orders for new injuries. Additionally, the resident's care plan was not updated with meaningful interventions following the identification of pressure injuries. Another resident experienced a delay in the treatment of a pressure injury, with inconsistent evaluations and contradictory documentation regarding the condition of the injury. The facility staff failed to implement hospice-provided wound care orders, and there was a lack of documentation regarding the notification of the physician and guardian about the pressure injury. The resident's care plan was not updated promptly, and there were discrepancies in the assessment of the pressure injury, with conflicting reports about its severity and condition. The facility also failed to ensure that another resident received appropriate wound care as per physician orders. There were multiple concurrent treatment orders for the resident's sacral wound, leading to confusion and missed treatments. The facility did not document any attempts to clarify these orders, resulting in inadequate wound care. Additionally, the facility did not consistently obtain and document weights for a resident with congestive heart failure, as required by the treatment plan. The Director of Nursing acknowledged the lack of oversight and monitoring of pressure injuries and wounds, indicating systemic issues in the facility's wound management program.
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.
