Optalis Health & Rehabilitation Of Wyoming
Inspection history, citations, penalties and survey trends for this long-term care facility in Wyoming, Michigan.
- Location
- 625 36th Street Sw, Wyoming, Michigan 49509
- CMS Provider Number
- 235441
- Inspections on file
- 24
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Optalis Health & Rehabilitation Of Wyoming during CMS and state inspections, most recent first.
A resident with Type 1 DM had a low BG identified, was told by an LPN to eat cookies, and was left without a timely BG recheck or documented ongoing assessment, contrary to the facility’s hypoglycemia policy. Later, the resident was found unresponsive with critically low BG and low O2 saturation, with no documentation that ordered glucagon or supplemental O2 were provided before EMS arrival, despite existing hypoglycemia treatment orders. Two additional residents with Type 2 DM had orders for nightly Lantus with parameters to hold if BG was below a specified level, yet BG checks were either not ordered routinely or not performed and documented on multiple days, while Lantus was still administered without recorded BG values or documented refusals.
Surveyors identified multiple food service and sanitation failures, including lack of hand towels at the only kitchen handwashing sink, a leaking dining room hand sink, and a non-operational cookline hood with filters removed for several days. Resident food in the pantry refrigerator was held beyond the facility’s stated 3-day limit for TCS items, and an expired therapeutic nutrition supplement product was stored with other supplements. Kitchen staff were observed handling clean dishes and resuming food preparation after other tasks or leaving the kitchen without required handwashing, and changing gloves without washing hands. The dish machine’s sanitizing rinse did not reach required temperatures for hot water sanitization, failing to achieve the minimum plate surface temperature needed for effective sanitization.
A resident with an infected hip replacement and impaired mobility reported that a CNA told her to stop using her call light, stated they would not return, then manipulated the bed controls and call light before leaving the room. The resident later awoke needing the bathroom, could not locate the call light, and subsequently had a bowel movement and urinated in bed, leaving her devastated and embarrassed. Another CNA entering after shift change found the resident upset, the bed saturated with urine and feces, and the call light wrapped with the bed remote on the floor, out of the resident’s sight and reach.
Two residents experienced significant clinical changes without provider notification. One resident with type 1 DM had multiple blood glucose readings in the 400–551 range despite an order to notify the physician for values above 200, and there was no documentation that the provider was informed. Another resident with heart disease and a pacemaker reported left-sided chest pain, received nitroglycerin, and had elevated BP and reduced O2 sats documented, but only the spouse was notified and there was no record of provider notification or entry in the provider communication log. The DON confirmed the absence of documentation in both cases.
The facility failed to prevent and monitor misappropriation of medications for two residents when an RN accepted and retained a GLP-1 (Ozempic) from the pharmacy that later could not be located, and only one LPN dispensed all PRN Norco doses to a cognitively intact resident whose pain was controlled with scheduled Tylenol and who reported not requesting the narcotic. Controlled drug records showed a missing Norco tablet that could not be accounted for, and the DON acknowledged that a single nurse exclusively dispensing a narcotic over time appeared suspicious for diversion.
A resident with dementia, anxiety, and bipolar disorder, but assessed as cognitively intact, reported that a CNA yelled at him during a dispute about a roommate’s urinal, and a CNA witness documented that the resident described the aide screaming at him and that he appeared fearful. Although the incident was reported internally and an investigation file and risk management forms were created, the resident’s EHR contained no documentation of the allegation, the verbal altercation, or any related behavioral episodes or psychosocial assessments during the period in question. The DON and NHA confirmed that such allegations were recorded only in internal incident and risk management systems, not in the resident’s medical record, resulting in incomplete and inaccurate documentation contrary to accepted professional standards.
A resident with esophageal cancer and obstruction, receiving enteral nutrition, had their tube feeding paused and restarted by a CNA who was not trained or authorized to perform this task. Interviews with the DON and an LPN confirmed that only trained staff should handle tube feedings, but it was reported that CNAs regularly performed this action, contrary to facility policy.
The facility failed to ensure call lights were within reach for residents, compromising their ability to alert staff for assistance. A resident with dementia and mobility issues was repeatedly observed with her call light on the floor, out of reach. Another resident was unaware of the call light's location due to it being hooked through the bed frame. A CNA confirmed that staff should check call light placement, indicating a lapse in protocol adherence.
A facility failed to adhere to professional standards for medication administration for a resident with a seizure disorder. The resident was prescribed Vimpat 50 mg twice daily, but the medication ran out on January 12, 2025, and was not available until January 16, 2025. Despite this, the Emar showed a dose was given on January 14, 2025, which was not accounted for in the Control Substance Record. The Unit Manager confirmed the medication was not available, indicating a failure to maintain accurate documentation.
The facility failed to implement Enhanced Barrier Precautions and Contact-Based Precautions for three residents, leading to infection control deficiencies. Nurses did not follow gown requirements, and Contact Precautions were delayed for two residents. Additionally, IV administration protocols were not followed for a resident, risking infection. The facility also neglected its water management plan, failing to address abnormal legionella levels, potentially affecting all residents.
A resident self-administered a nebulizer treatment without proper assessment or supervision, as the facility failed to perform necessary assessments and obtain a physician order for self-administration. The resident had diagnoses including pneumonitis and COPD, and the facility's policy requires an interdisciplinary team assessment for self-administration, which was not conducted. An LPN acknowledged the need for supervision during treatments but cited time constraints as a barrier.
A facility failed to monitor and assess the use of psychotropic medications for a resident with schizoaffective disorder, bipolar disorder, and PTSD. Despite a care plan requiring medication monitoring, there was no documentation of monitoring for side effects or effectiveness. An LPN confirmed the absence of documentation, highlighting a failure to follow the facility's policy on psychoactive drug use.
The facility failed to label and date medications, dispose of expired medications, and secure medication carts. An insulin pen was improperly stored, and several medications lacked proper labeling. Personal belongings were found in a medication room, and medication carts were left unlocked and unattended. These issues indicate deficiencies in medication management practices.
The facility failed to provide coordinated hospice care for two residents, resulting in a lack of collaborative care. One resident with multiple sclerosis was unaware of the hospice staff's visit schedule, and there was no documentation of hospice participation in care conferences. Another resident with hemiplegia reported severe pain, and the RN was unaware of the hospice staff's visit schedule. The facility's social worker could not locate documentation of hospice participation in care conferences, and the last hospice records were dated over a week prior.
A resident with heart disease and hypertension was not administered the pneumococcal vaccine PCV20 upon admission, despite being due and having consented. The resident's immunization status remained pending, and the DON acknowledged the oversight, noting a lack of process to ensure timely vaccination. Facility policy required offering the vaccine upon admission unless contraindicated or previously vaccinated.
Failure to Competently Manage Hypoglycemia and Follow Insulin Parameters for Diabetic Residents
Penalty
Summary
The deficiency involves failures in recognizing and managing hypoglycemia and in administering insulin according to physician orders for three diabetic residents. One resident with Type 1 diabetes had orders for blood glucose (BG) checks before meals and at bedtime, with specific hypoglycemia treatment orders including oral glucose tablets and glucagon nasal spray. On the morning in question, an LPN obtained a BG of 69 mg/dL, documented only in a nursing note, encouraged the resident to eat cookies, and then left the room without rechecking the BG or reassessing the resident as required by the facility’s hypoglycemia policy. There was no documentation of a repeat BG within approximately 15 minutes, no documentation that the resident’s clinical status was monitored during this period, and no documentation that the resident was medically stable until vital signs were taken about 1 hour and 45 minutes later. When the resident was next assessed, vital signs showed an oxygen saturation of 84% on room air and a BG of 46 mg/dL. Documentation and interviews indicate the resident was unresponsive at that time, with a critically low BG and elevated blood pressure. Staff did not document application of supplemental oxygen after the low oxygen saturation was identified, and there is no documentation that ordered emergency hypoglycemia treatments (glucagon) were administered by facility staff prior to EMS arrival. EMS and hospital records reflect that staff reported the resident’s sugar had been found low earlier, that the resident had been told to eat and left alone, and that staff stated they did not have glucagon or glucose to give, despite existing orders for oral glucose tablets and glucagon nasal spray. EMS found the resident unresponsive, hypoxic, and with a BG of 24 mg/dL, and administered glucagon. The deficiency also includes failures to follow physician orders for insulin administration parameters for two other residents with diabetes. One resident with Type 2 diabetes had an order for nightly Lantus insulin with instructions to hold the dose if BG was less than 100 mg/dL, and to obtain a BG prior to administration. Review of records showed multiple dates on which no BG was assessed in the evening, yet all Lantus doses were documented as given, with no rationale or documentation of BG refusals. Another resident with Type 2 diabetes had an order for nightly Lantus with instructions to hold if BG was less than 100 mg/dL, but there was no corresponding order for routine BG assessments. Over a several-week period, only four BG readings were documented, while Lantus was administered on most nights, including nights without a recorded BG. The DON confirmed that BGs were not consistently obtained prior to insulin administration and that nurses were expected to review full order summaries to follow provider-ordered parameters.
Multiple Food Service Sanitation and Hand Hygiene Failures in Kitchen and Dining Areas
Penalty
Summary
The deficiency involves multiple failures in kitchen sanitation and food handling practices observed during a survey. Surveyors observed that the only designated handwashing sink in the dishwashing room did not have hand towels readily available, contrary to FDA Food Code requirements for hand drying provisions. In the dining room, the hand sink was leaking cold water, and the dietitian reported that the faucet had been repaired the prior week for the same issue, indicating the plumbing system was not maintained in good repair. Additional observations showed that the ventilation hood system over the cookline was not properly maintained. Filters were missing from the face of the hood ventilation system, and the dietitian stated the filters had been out for cleaning since several days prior and that the hood was not operational, then turned the hood off. This condition did not meet FDA Food Code requirements that ventilation hood systems be sufficient in number and capacity to prevent grease or condensation from collecting on walls and ceilings. Surveyors also identified improper food storage, expired products, and inadequate hand hygiene and dish sanitization practices. Resident food stored in the pantry refrigerator included a foam takeout container with an orange/brown sauce dated beyond the facility’s stated 3-day holding policy for time/temperature controlled for safety food. A Vital therapeutic nutrition supplement with an expiration date already passed was found on shelving with other therapeutic nutrition products. Kitchen personnel were observed handling clean dishes after other tasks without washing their hands, removing gloves and donning new ones without handwashing, and leaving and re-entering the kitchen to resume food preparation without washing hands, contrary to FDA Food Code handwashing requirements. The dish machine’s sanitizing rinse failed to reach the required 180°F at the gauge and 160°F plate surface temperature, with a DishTemp plate registering only 146°F, which did not meet FDA Food Code standards for hot water sanitization temperatures.
Failure to Maintain Resident Dignity and Access to Call Light
Penalty
Summary
The deficiency involves the facility’s failure to treat a resident in a dignified manner and to honor her rights to self-determination and communication. The resident was an adult female admitted with an infected right hip replacement and difficulty walking. In an interview, she reported that very early one morning a CNA entered her room and told her to stop using her call light, stating that the CNA had already been in the room multiple times and would not be coming back again. The resident stated that the CNA then manipulated her bed controls and call light and left the room. The resident later awoke around 5:00 AM needing to use the bathroom and was unable to locate her call light to request assistance. According to the resident, because she could not find the call light, she had a bowel movement and urinated in her undergarments, which left her feeling devastated and embarrassed. Another CNA, who entered the room after shift change that morning, reported smelling feces, finding the resident very upset, and observing that the sheets were saturated with urine and feces. This CNA also reported that the call light was wrapped together with the bed remote, on the floor, out of the resident’s sight and reach. The CNA implicated in the incident was no longer employed at the facility and was not available for interview.
Failure to Notify Providers of Significant Changes and Abnormal Clinical Findings
Penalty
Summary
The deficiency involves the facility’s failure to notify providers of significant changes in condition and abnormal clinical findings for two residents. One resident with type 1 diabetes mellitus and an order to obtain blood sugars before meals and at bedtime, with instructions to notify the physician for blood glucose levels less than 60 or greater than 200, had multiple documented blood sugar readings far above the ordered threshold. These included values in the 400–551 range on numerous dates. Review of the electronic medical record showed no documentation that the provider was notified of any of these elevated blood sugar results. When surveyors requested evidence of provider notification, the Nursing Home Administrator acknowledged there was no documentation, and the DON stated that the expectation was for licensed nurses to notify the provider of elevated blood sugars, typically when readings were greater than 450. The second resident, who had heart disease and a cardiac pacemaker, experienced an episode of left-sided chest pain for which nitroglycerin was administered. Vital signs at that time included a blood pressure of 158/90, pulse 73, respirations 18, temperature 97.3, and oxygen saturation of 93% on room air. Nursing documentation indicated that the nurse notified the resident’s wife of the condition and that she advised continued monitoring and possible hospital transfer if the condition worsened. However, there was no documentation in the electronic medical record or provider communication log that the provider was notified of this chest pain episode, despite the resident’s complex cardiac history. The DON confirmed there was no documentation of provider notification. The report cites a nursing textbook outlining failure to communicate abnormal assessment data or significant changes in status as a common negligent act.
Failure to Prevent and Monitor Misappropriation of Medications
Penalty
Summary
The facility failed to prevent misappropriation of a resident’s medication when a nurse accepted and retained possession of a GLP-1 medication (Ozempic) for a male resident with type 2 diabetes and the medication subsequently could not be located. According to the facility-reported incident, the RN accepted the Ozempic from the pharmacy late at night and had it in her possession, then attempted to obtain a co-signature from an LPN after she already had the medication. The LPN found this concerning and reported it to the DON early the next morning. When first shift staff arrived, the Ozempic could not be found, and the packing slips for all medications delivered were recovered except for the Ozempic. Multiple co-workers reported that the RN frequently communicated or inquired about medications for weight loss. The facility also failed to adequately monitor and investigate potential or ongoing misappropriation of a resident’s narcotic medication when only one LPN dispensed all doses of a PRN narcotic (Norco) to a cognitively intact female resident over an extended period, and a missing tablet was documented without resolution. Review of the controlled drug records showed that from late October to early January, only one nurse dispensed the Norco, and an entry indicated a correct count had been completed but one tablet was missing and could not be accounted for. The resident reported that her pain was effectively controlled with scheduled Tylenol at night and that she did not request the PRN Norco. The DON confirmed that the pattern of only one nurse dispensing the narcotic appeared suspicious for diversion, and the NHA confirmed the resident’s report that she did not require the PRN Norco for pain control.
Failure to Document Resident Abuse Allegation and Related Assessments in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a cognitively intact resident with multiple psychiatric diagnoses, including dementia with agitation and psychotic disturbance, anxiety, and bipolar disorder. The resident’s admission record and MDS showed he was cognitively intact, with a BIMS score of 15. On or around late September, the resident reported to staff that a CNA had yelled at him when he complained about his roommate’s urinal being left in the bathroom, and he stated that the interaction was upsetting to him. In a typed interview statement, the resident reported that the aide spoke to him in a way he did not like, but he did not remember the aide’s name and stated he was not scared and felt safe in the facility. A CNA’s written statement documented that the resident described arguing with a specific CNA about the urinal being left in the bathroom, that he had removed it and thrown it on the floor, and that the CNA was screaming at him until an RN intervened. The CNA also documented that the resident appeared fearful and stated he would protect himself from the aide if necessary, and that she immediately reported the incident to the facility abuse coordinator. Despite these reports and the internal investigation, a review of the resident’s electronic medical record for the period surrounding the alleged incident showed no documentation of the resident’s complaint, the alleged verbal altercation, or any related behavioral episodes such as yelling or verbal aggression by either the resident or staff. Interviews with the DON and NHA confirmed that allegations of staff yelling or swearing at residents were documented only in the facility’s incident reporting system and on internal risk management forms, which are not part of the resident’s medical record. The DON stated she was unsure whether such accusations would be documented in the resident’s progress notes and indicated that staff would definitely document if a resident yelled or swore at staff, but not necessarily if staff were accused of yelling at a resident. The NHA stated that the facility did not document the resident’s initial accusation in the medical record and that related information was kept in an investigative file separate from the record. This practice resulted in the absence of any documentation in the resident’s electronic medical record regarding the allegation, the resident’s psychosocial status, or any follow-up assessments during the relevant time frame, contrary to accepted professional standards for nursing documentation as described by the American Nurses Association.
Untrained Staff Paused and Restarted Enteral Feeding
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) paused and restarted enteral tube feeding for a resident diagnosed with esophageal cancer and esophageal obstruction, who was receiving enteral nutrition per physician's orders. The CNA reported pausing the tube feeding prior to providing care and then restarting it afterward, despite not being trained or authorized to perform this task. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that only trained staff, such as licensed nurses and med techs, were permitted to pause and restart tube feedings. Additional staff interviews revealed that CNAs regularly performed this action, indicating a lack of adherence to facility policy regarding tube feeding management.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for residents, which is a critical aspect of accommodating their needs and preferences. Resident #305, a female with dementia, unsteadiness, cognitive communication deficit, and lack of coordination, was observed multiple times with her call light on the floor, out of sight and reach. Despite requiring assistance for daily activities, she stated she would manage on her own, indicating a lack of awareness or ability to use the call light effectively. Observations on consecutive days showed the call light consistently out of reach, whether she was in bed or in a wheelchair. Another resident in bed 104-A was also found with the call light cord hooked through the bed frame, leaving the call light on the floor and inaccessible. This resident was awake and watching television but was unaware of the call light's location when asked. A CNA confirmed that staff are expected to check call light placement each time they enter a room, suggesting a lapse in adherence to this protocol. These observations highlight a failure in ensuring residents can alert staff when needed, compromising their ability to receive timely assistance.
Medication Administration Discrepancy for Resident with Seizure Disorder
Penalty
Summary
The facility failed to adhere to professional standards for medication administration for a resident with a seizure disorder. The resident, a male with a history of seizure disorder, frequent falls, weakness, and unsteadiness, was prescribed Vimpat (Lacosamide) 50 mg twice daily. A review of the Control Substance Record indicated that the medication was last administered on the morning of January 12, 2025, and had run out, with no additional pills available until January 16, 2025. Despite this, the Electronic Medication Administration Record (Emar) showed that the resident was given a dose of Vimpat on the evening of January 14, 2025, which was not accounted for in the Control Substance Record. During an interview, the Unit Manager confirmed that the Vimpat was not available in the facility on the evening of January 14, 2025, and could not explain why it was recorded as administered. This discrepancy indicates a failure to maintain accurate and complete documentation of medication administration, as required by professional standards. The report highlights the importance of ensuring that medication records are truthful and complete to maintain the quality of care for residents.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and Contact-Based Precautions for three residents, leading to deficiencies in infection control. One resident, who was cognitively intact and required extensive assistance, had a sign on their door indicating the need for EBP, including wearing gloves and a gown. However, two nurses entered the room with only gloves, disregarding the gown requirement. Another resident, admitted with a wound infection and paraplegia, was placed on EBP but did not have Contact Precautions implemented until over six weeks later, despite a physician's order. Similarly, a third resident with sepsis was not placed on Contact Precautions until 25 days after admission, despite being on EBP. The facility also failed to follow policies and procedures for IV administration for one resident. During an observation, a nurse was seen using undated tubing for an IV antibiotic and did not disinfect the port before reconnecting the tubing. The nurse admitted to not having an answer for why the port was not cleaned and mentioned a lack of tubing as a reason for the improper practice. This failure to adhere to IV administration protocols posed a risk of infection for the resident. Additionally, the facility did not implement its water management plan to reduce the risk of legionella and other pathogens, potentially affecting all residents. A water analysis revealed abnormal levels of legionella, but the facility did not take the required remedial actions, such as enhanced monitoring or notifying the Regional Director of Maintenance. The Director of Maintenance admitted to not being familiar with the entire water management plan, and housekeeping staff were not properly instructed to flush sinks, as required by the plan.
Failure to Assess and Supervise Self-Administration of Medication
Penalty
Summary
The facility failed to perform a resident assessment and obtain a physician order for the self-administration of a breathing treatment for a resident, resulting in the resident self-administering a nebulizer treatment without appropriate supervision and assessments. The resident, identified as R225, was admitted to the facility with diagnoses including pneumonitis, heart disease, lack of coordination, and blindness in one eye. During an observation, it was noted that R225 was in his room starting a breathing treatment without being assessed by the registered nurse (RN) present, who also did not perform a post-assessment after the treatment was completed. The Medication Administration Record (MAR) indicated an order for Arformoterol Tartrate Inhalation Nebulization Solution to be administered twice daily for COPD. However, there were no orders, assessments, or care plans for the self-administration of medications in the resident's electronic medical record. The facility's policy on self-administration of medications requires an interdisciplinary team assessment and periodic re-evaluation, which was not conducted for R225. Additionally, a Licensed Practical Nurse (LPN) admitted that nurses are supposed to stay with residents during nebulizer treatments but cited time constraints as a reason for not doing so.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor and assess the use of psychotropic medications for a resident identified as R19. The resident, who was admitted with diagnoses of schizoaffective disorder, bipolar disorder, and PTSD, was observed to be tearful and intermittently crying during an interview. The care plan for R19 included administering medications as ordered and monitoring for side effects and effectiveness, yet there was no documentation of such monitoring in the medical records. A behavioral health document indicated that hydroxyzine was discontinued, and the plan was to monitor for changes in mood or behaviors for 14 days, but this monitoring was not documented. During an interview, an LPN confirmed that there was no documentation in the MAR for monitoring R19's behaviors or side effects of psychotropic medications, although such monitoring was documented for another resident. This lack of documentation and monitoring represents a failure to adhere to the facility's policy on psychoactive drug use, which aims to prevent excessive dosing, duration, and ensure adequate monitoring and indications for use.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly label and date mark opened medications, dispose of expired medications, and secure medication carts. During an observation of a medication cart on the 100 hall, it was found that a Flex Touch 1000 insulin pen, which should have been refrigerated until opened, was improperly stored in the cart. Additionally, a vial of Lantus insulin, two bottles of Systane eye drops, Polymyxin antibiotic eye drops, and Dorzolamide/Timol eye drops were not labeled with the resident's name or the date they were opened. A registered nurse confirmed these labeling issues and acknowledged that the insulin pen should have been refrigerated. Furthermore, a personal belonging, specifically a large black purse, was found stored in a medication room, which was confirmed by the unit manager to be inappropriate. The facility's Medication Access and Storage Policy, adopted on 7/11/2018, did not address the labeling of medications, which contributed to the deficiencies observed. Additionally, during separate observations, two medication carts were found unlocked and unattended in the hallways. In one instance, an LPN admitted to forgetting to lock the cart, and in another, a medication treatment cart was left unlocked with no nurses in view. The LPN responsible for the cart confirmed that it should have been locked when unattended. These lapses in securing medication carts and improper labeling and storage of medications highlight significant deficiencies in the facility's medication management practices.
Lack of Coordinated Hospice Care for Two Residents
Penalty
Summary
The facility failed to provide coordinated hospice care for two residents, resulting in a lack of collaborative care. Resident R16, a female with multiple sclerosis and neuromuscular dysfunction, was observed to be unaware of the hospice staff's visit schedule, except for a hospice aide who visited on Wednesdays without a set time. The facility's social worker could not find documentation confirming hospice participation in R16's care conferences, and there was no record of weekly hospice visits in her electronic medical records. An email request for hospice records revealed that the hospice aide provided weekly showers, but it was unclear if other services were provided. Resident R41, a female with hemiplegia, dysphagia, and chronic kidney disease, reported severe stomach pain and was receiving Tylenol for pain management. The RN was unaware of the hospice staff's visit schedule for R41. The facility's social worker could not locate documentation of hospice participation in R41's care conferences, and the last hospice records were dated over a week prior. Progress notes indicated that R41 experienced severe pain and nausea, but there was no indication of hospice notification regarding her condition change. The facility's NHA found documentation that R41 refused hospice nurse aide services, but there was no explanation for the lack of hospice nurse documentation in her medical record.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to a resident, identified as Resident #29, who was reviewed for immunizations. Upon admission, the resident had pertinent diagnoses including heart disease and hypertension and was due for the pneumococcal vaccine PCV20. The Michigan Care Improvement Registry indicated that the resident was due for this vaccine since admission, and the resident had consented to receive it. However, the resident's electronic health record showed the pneumococcal status as pending. The Director of Nursing acknowledged that the vaccine was due upon admission and should have been scheduled by the unit manager, but this did not occur. Additionally, there was uncertainty about whether the Infection Preventionist had a process to ensure timely offering of pneumococcal vaccines to residents. The facility's policy stated that all residents should be offered pneumococcal vaccines upon admission unless contraindicated or previously vaccinated.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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