Pinnacle Care Of Battle Creek
Inspection history, citations, penalties and survey trends for this long-term care facility in Battle Creek, Michigan.
- Location
- 675 Wagner Drive, Battle Creek, Michigan 49017
- CMS Provider Number
- 235536
- Inspections on file
- 31
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Pinnacle Care Of Battle Creek during CMS and state inspections, most recent first.
The facility did not employ a qualified RD and lacked a certified Dietary Manager with LTC experience to oversee nutrition services for its residents. A newly hired DM, with only a Food Safety Manager Certification and prior work in a bakery and hotel, did not meet the facility’s own job requirements for the role and was unclear about her responsibilities for weight loss and therapeutic diets. She relied on a food vendor for menu questions and believed nursing staff were responsible for high-calorie supplements and specialized diets. The former RD reported she had not worked at the facility for several months and had previously handled weight monitoring, therapeutic diets, menu adequacy, education, and QAPI weight reports. The NHA acknowledged the DM was only in training for certification and that an RD, though reportedly on staff, had not been present recently.
The facility did not implement an effective QAPI program, as evidenced by a QAPI policy that lacked implementation and review dates, had not been approved by the QAPI team, and appeared to be a generic document from another company. The NHA confirmed the policy was not in use and could not explain the lack of approval. Although several PIPs addressing annual staff competencies, required CNA continuing education hours, and dietitian requirements had been presented to the QAPI committee, leadership was unaware that the facility would not achieve substantial compliance with these areas by the stated compliance date, affecting all residents.
The facility failed to ensure that nursing staff held current, regulation‑compliant CPR certifications. Review of the CPR binder showed that one RN had no CPR certification on file, while an RN and an LPN held CPR certifications obtained solely through online courses without any in‑person, hands‑on training. Both nurses with online‑only certifications stated they would be expected to assist during a code. The facility’s policy and nurse job descriptions require CPR/BLS certification, specifically American Red Cross or American Heart Association BLS/CPR, and regulations require hands‑on, instructor‑led CPR training, which was not met for these three nurses.
The facility did not ensure that nurses and CNAs had documented competencies to provide care that maximizes each resident’s well-being. Review of five nurse personnel files showed no evidence of new hire or annual education, training, or competency assessments, despite a written policy requiring structured orientation, preceptors, and completed competency evaluation forms to be filed in HR. The HRD confirmed there were no formal competencies or required online/hands-on training in place, and an RN reported that monthly in-services had stopped and he did not recall yearly competency evaluations. Another RN described orientation as limited to HR paperwork, policy review, and brief job shadowing, with no hands-on training or competency checklists.
The facility did not provide or document required in-service training and competency evaluations for CNAs, including dementia care and abuse prevention education. Review of multiple CNA files showed no evidence of annual or new hire training or skills competencies. The HR director confirmed that there were no formal competencies or in-services completed and no required online or hands-on training in place. A CNA reported not receiving any formal competency or skills check at this facility, and the DON acknowledged that there had been no established process for annual competencies and that new hire orientation had been limited to verbal information and informal on-the-floor orientation.
The facility failed to ensure its activities program was directed by a qualified professional. An Activities Director, who had been in the role for several months and was not yet certified, reported being responsible for scheduling, implementing, and evaluating resident activities. She stated she believed she met the job requirements because she was eligible for certification and was taking a class. Review of the facility’s job description showed specific qualification requirements, including licensure/registration if applicable and defined experience, certification eligibility, or completion of a state-approved course. The NHA acknowledged that, based on these requirements and her understanding of the regulation, the current Activities Director did not meet the qualifications for the position.
Two cognitively intact male residents with behavioral and psychiatric diagnoses were involved in a resident-to-resident altercation in a dining area when one resident’s wheelchair bumped into the other’s wheelchair, prompting the second resident to strike the first in the face with a closed fist, causing a lip laceration and bleeding, and to make verbal threats and profane remarks about the incident. The facility’s investigation substantiated that abuse occurred and that the injured resident sustained an injury, demonstrating a failure to protect residents from physical and verbal abuse by other residents.
A resident with dementia, a progressive neurologic disorder, and anxiety was transferred to a hospital after episodes of exit-seeking and brief agitation, despite prior documentation that he was generally pleasant and redirectable on 1:1 supervision. After this transfer, the facility discontinued his orders and care plans, did not document providing a Transfer Notice or bed-hold information to the resident or his representative, and later decided not to allow him to return, citing behavior and the expiration of the bed-hold period. Interviews with the SW, DON, and business development staff showed uncertainty or lack of compliance with required transfer and discharge procedures, while the census and bed board reflected multiple open beds, including the resident’s former room, even as the psychiatric hospital reported the facility had stated there were no beds available and sought alternative placement options.
A resident with dementia, agitation, and a progressive neurologic disorder experienced increasing agitation, exit-seeking, and physical aggression, leading to transfer to a hospital after attempts at redirection and provider contact. Review of the EMR showed the resident’s orders and care plans were later discontinued and the resident was no longer in the facility, but there was no documentation that a written transfer notice or the facility’s bed-hold policy was provided to the resident or representative. The DON confirmed that such notices were expected at the time of transfer but could not locate any evidence that the responsible party received written notification of the transfer or bed-hold policy.
A resident with severe cognitive impairment and dementia was not protected from sexual abuse by another resident with moderate cognitive impairment and a history of sexually inappropriate behavior. Two separate incidents occurred in which the resident was subjected to inappropriate touching, first in a private room and later in a common area, despite care plans indicating the risk and inability to consent. Staff did not immediately intervene during the first incident, and the facility failed to prevent further contact, resulting in repeated abuse.
Surveyors identified that the facility failed to maintain safe hot water temperatures, with multiple resident rooms registering well above 120°F, including rooms of residents with cognitive impairment. There was also a failure to investigate and implement new interventions after repeated falls by a resident with dementia, and the care plan was not updated accordingly. Additionally, a visually impaired resident was allowed unsupervised access to chewing tobacco and a spit cup in his room, with no facility policy addressing this issue and staff aware of the ongoing practice.
Two residents experienced deficiencies in pressure ulcer care, including failure to update physician orders, incomplete wound documentation, lack of pressure-relieving devices, and inadequate pain management during wound care. These actions led to worsening wounds, unrelieved pain, and increased risk of skin breakdown.
Surveyors identified failures in cleaning and maintaining food service equipment, improper date marking of ready-to-eat foods, and use of non-pasteurized shell eggs. Multiple kitchen appliances were found with food residue, and maintenance issues were noted with the dish machine and walk-in cooler. Facility policies for sanitation and food safety were not consistently followed, affecting all residents who consumed food.
The facility did not maintain an effective QAPI program, failing to identify and address issues such as hot water temperature and call light accessibility. Despite resident complaints about the lack of hot water, there was no documented follow-up or ongoing monitoring in QAPI records, and the administrator was unaware of any related discussions or performance improvement plans.
Surveyors identified widespread deficiencies in cleaning and maintenance throughout the facility, including soiled and damaged equipment, missing safety features, non-functional lighting, and the presence of human waste in resident areas. Despite having policies for maintenance and cleaning, the facility did not document or address these issues, resulting in an environment that was not adequately safe or sanitary for residents, staff, or visitors.
A resident with severe cognitive impairment and psychiatric diagnoses was prescribed PRN Lorazepam for anxiety, but the order was not discontinued or reassessed after 14 days as required. The DON confirmed that the order remained active without proper physician documentation or evaluation, resulting in a deficiency for failure to comply with federal regulations on psychotropic medication use.
Six residents were found without accessible or functional call lights, with some using ineffective alternatives or resorting to yelling for help. Staff interviews and observations confirmed that call lights were often out of reach, not working, or mistaken for other devices, contrary to facility policy requiring call lights to be accessible and secured for resident use.
The facility failed to follow physician orders and provide proper assessment and care for four residents, including not maintaining head-of-bed elevation for a resident with respiratory failure, not assessing or monitoring edema for a resident after hospital discharge, not securing or monitoring a urinary catheter leading to a significant penile injury, and not implementing wound care orders for a resident admitted with abdominal wounds.
Multiple residents experienced significant delays in call light responses and unmet care needs due to insufficient nursing staff. Residents reported waiting from 35 minutes to over an hour for assistance, with some left in soiled briefs for extended periods. Staff interviews and Resident Council feedback confirmed frequent short staffing, particularly on nights and weekends, leading to prolonged wait times and unaddressed care needs.
The facility did not ensure that a licensed pharmacist conducted required monthly medication regimen reviews for multiple residents with complex medical needs, as evidenced by missing documentation for several months and staff unable to verify completion. Interviews revealed confusion over responsibility for these reviews, with the contracted pharmacy and a third-party pharmacist each indicating limited involvement.
Surveyors identified deficiencies involving improper medication labeling, storage, and administration. Staff were observed using medication bottles without expiration dates, disposing of pills in open trash containers accessible to residents, and leaving medications at the bedside without ensuring administration. Additionally, a resident was found with marijuana gummies, which were not managed according to facility policy, and staff were unaware of proper procedures for handling such substances.
Nine out of ten residents reported not being consistently offered bedtime snacks, with some stating that snacks were rarely provided and lacked variety. Dietary staff delivered snack trays to each unit, but nursing staff were responsible for serving them, and trays were often returned with most items untouched, indicating snacks may not have been offered as required by facility policy.
The facility did not effectively maintain the resident call system for 61 residents, as evidenced by a lack of maintenance work orders and a resident expressing dissatisfaction with the current system. Although the call system was observed to be functioning in several rooms, facility policy requiring immediate reporting and alternative solutions for call system issues was not followed, increasing the risk of delayed emergency response.
A resident with legal blindness and other health conditions was subjected to repeated verbal abuse by a roommate, with staff and other residents aware of the ongoing behavior. Despite these reports and observations, the facility did not implement care plan interventions to address the inappropriate behavior until after the incidents had occurred, failing to uphold the resident's right to dignity and a safe environment.
Two residents with severe cognitive impairment and dementia were administered psychotropic medications without documented informed consent from their guardians. In both cases, the required consent forms were not obtained or available for review at the time of the survey.
A resident with a history of stroke, vascular dementia, and chronic kidney disease had a signed DNR form in their medical record, but the EMR banner continued to display full code status. Nursing staff relied on the EMR banner for code status during emergencies, and a discrepancy was identified between the banner and the DNR documentation. The social worker responsible for advance directives reported that the code status was not updated in the EMR banner after the physician signed the DNR form, due to a possible lapse in communication.
A resident with legal blindness and other health conditions reported a missing DVD set, which was important for his comfort and daily living. The family submitted a concern form to the facility, but there was no documentation or follow-up, and the facility could not locate the paperwork. This resulted in the resident's personal belongings not being safeguarded or made available for use.
A resident with severe cognitive impairment and psychiatric diagnoses received a PRN order for Lorazepam that was not discontinued after 14 days, nor was there physician documentation to justify continued use. The DON confirmed the order should have been reevaluated and discontinued as required.
A resident with multiple medical conditions was transferred to the hospital and did not return, but the facility did not provide the required written notice of transfer/discharge to the resident, their representative, or the ombudsman. Facility leadership reported they were unaware of this requirement and did not document or send the notices.
A resident with severe cognitive impairment, muscle contractures, and a documented unstageable pressure ulcer on the left heel was not accurately assessed by the facility. Despite wound care notes detailing the ulcer, the facility's MDS assessment failed to reflect its presence, indicating a lack of comprehensive and timely assessment.
A resident with vascular dementia, diabetes, and wheelchair dependence developed two new stage II pressure ulcers, but staff failed to complete a Significant Change in Status Assessment (SCSA) MDS as required. The responsible RN was unaware of the ulcers and did not initiate a care plan revision, resulting in a missed comprehensive assessment following a significant health decline.
The facility failed to accurately complete MDS assessments for three residents, including not documenting a diagnosis of depression despite a prescription for antidepressant medication, leaving cognition and mood sections unassessed for two residents, and not recording falls that were documented elsewhere in the medical record.
A resident with vascular dementia, diabetes, and wheelchair dependence developed two stage II pressure ulcers. Despite recommendations for a low air loss mattress and a pressure-relieving wheelchair cushion, these interventions were not implemented or documented in the care plan. The care plan did not address the presence of pressure ulcers or include specific interventions for pressure relief, and the MDS nurse was unaware of the wounds.
A resident with severe cognitive impairment and multiple diagnoses did not receive a required quarterly care conference. Documentation confirmed the last conference was held several months prior, and the next was missed due to staff turnover and scheduling delays, as acknowledged by facility staff.
A resident with severe cognitive impairment and major depressive disorder was left without meaningful engagement, as scheduled activities were not consistently implemented and activity staff failed to interact with residents. Observations showed the resident sitting unengaged for extended periods, while staff were seen using personal phones or working alone. Staff interviews confirmed that scheduled activities did not occur as planned and that inconsistent staffing contributed to the lack of engagement.
A resident with heart failure and respiratory failure was not provided with double protein portions as ordered by the physician, despite documented weight loss and a dietitian's intervention. Observations showed the resident received standard meal portions, and staff confirmed the expectation for double protein was not met.
Three medication errors were observed, including administration of an iron pill without a visible expiration date, giving Senna Plus without a specified dose in the physician's order, and nearly administering Losartin without checking required blood pressure parameters. These incidents resulted in a medication error rate of 12%, exceeding the acceptable threshold.
A resident was observed using oxygen tubing that had not been changed for over two weeks, contrary to facility policy requiring weekly changes. The ICP, who is also an RN, did not monitor or audit oxygen tubing changes, and the DON confirmed that regular audits and checks were expected but not performed.
Two residents with chronic conditions received the pneumococcal vaccine after initially declining it, but there was no documentation that they were educated on the benefits and potential side effects prior to administration. Both the DON and ADON/IP confirmed that CDC Vaccine Information Statements should have been provided, but no evidence of this education was found in the records.
The facility did not include the current year or shift times on daily nurse staffing postings, displaying only the date and total hours worked by RNs, LPNs, and CNAs for each shift. The DON indicated the Scheduler was using a form that may have been outdated.
A resident with severe cognitive impairment and multiple diagnoses did not receive an updated COVID-19 vaccine despite verbal consent from their DPOA, and facility leadership could not provide documentation or an explanation for the missed administration.
Two residents with severe cognitive impairment and dementia were given psychotropic medications, including an anti-anxiety and an antipsychotic, without the required signed consents. Family was not informed of a new medication order for one resident, and consent documentation was missing for both cases at the time of survey review.
The facility did not conduct or document the required annual emergency preparedness exercises, such as a second full-scale, tabletop, or facility-based drill, as confirmed by record review and interview with the Maintenance Director. This deficiency could affect all occupants during an emergency.
Surveyors observed 1-inch gaps between ceiling tiles and the base of exit signs at the entrances to both the South Hall and North Hall smoke compartment doors, near the Administrator's and DON's offices. These gaps resulted in the facility not meeting required flame spread ratings for interior finishes, as confirmed by the Maintenance Director.
Surveyors observed that a smoke detector head was not properly mounted to the ceiling at the North Smoke Doors exit into the administration hall, and another smoke detector head in the North Mechanical closet was covered with a plastic bag. These issues were confirmed by the Facility Maintenance Director during the survey.
Surveyors found that corridor doors, including those to the North Dining Room and a resident room, failed to latch properly or had excessive gaps, compromising their ability to resist smoke passage as required by fire safety regulations. These deficiencies were confirmed by the Maintenance Director during the survey.
Surveyors identified that the facility did not provide current documentation for required generator maintenance and testing, including monthly load tests, annual load bank tests, annual service, and annual fuel analysis, as required by NFPA standards.
The facility did not submit required plans to the Bureau of Fire Services for newly constructed walls between the Activities Office and Dietary Office, resulting in an unverified void area with unknown suppression coverage. No documentation was provided to surveyors, and the deficiency was confirmed by maintenance staff.
The facility did not provide documentation for required quarterly sprinkler flow tests and was found to have a sprinkler head in the therapy room that had not been replaced in over 50 years, as confirmed by the Maintenance Director.
Smoke compartment door #9 failed to close to a smoke-tight fit due to the door sweep catching on the floor, requiring staff assistance to close it from the magnetic release. This deficiency was confirmed by the Facility Maintenance Director and could affect 30 occupants during a fire emergency.
Lack of Qualified Dietary Leadership and Absence of Registered Dietitian
Penalty
Summary
The facility failed to employ sufficient qualified staff to manage food and nutrition services for a census of 62 residents. The Dietary Manager (DM) had been in the role for approximately four weeks, had no prior LTC dietary experience, and held only a Food Safety Manager Certification, not a Dietary Manager Certification. Review of her resume showed no certification or degree in dietary management and prior work limited to a grocery store bakery and a hotel. The facility’s own job description for the Dietary Manager required certification or specific education/experience in food service management, including LTC experience or equivalent qualifications, which the current DM did not meet. The Nursing Home Administrator acknowledged that the DM was only taking classes to become certified and that, in the past, she had required LTC experience for this role. The facility also failed to employ a Registered Dietitian (RD) to oversee residents’ nutritional needs. The DM did not know if the facility currently had an RD and reported that she relied on the food vendor for menu questions. She stated that nursing staff were responsible for notifying the kitchen about residents needing high-calorie supplements or therapeutic diets and was unaware of any role she had in addressing weight loss. The former RD reported she had not been employed since approximately October/November of the prior year, with only one day in the building in December, and that when employed she worked 20 hours per week and was responsible for monitoring resident weights, therapeutic diets, menu adequacy, menu adjustments, education, and generating a weight change report for QAPI. In a follow-up interview, the DM believed the RD was responsible for assessing residents’ nutritional needs and thought nurses were responsible for developing and evaluating regular and therapeutic diets, including food and liquid textures, while she assumed she might be responsible for staff education programs. The NHA reported she had been told the facility had an RD on staff but that this person had not been seen recently and that they were trying to find a full-time RD.
Failure to Implement an Effective QAPI Program
Penalty
Summary
The facility failed to develop and maintain an effective Quality Assurance and Performance Improvement (QAPI) program that identified and prioritized quality deficiencies, analyzed their underlying causes, and implemented effective corrective actions. Surveyors reviewed the facility’s QAPI policy and found that the document titled “Quality Assurance and Performance Improvement (QAPI)” had no entries for Date Implemented, Date Reviewed/Revised, or Reviewed/Revised by. The document also bore a 2025 copyright and a heading from another company, indicating it was not a facility-specific, implemented policy. During interview, the Nursing Home Administrator (NHA) confirmed that this QAPI policy had not been implemented by the facility and could not explain why it had not been approved. The NHA reported that the facility had several Performance Improvement Plans (PIPs) that had been approved by the QAPI team, including plans related to annual competencies, annual 12 hours of continuing education for CNAs, and dietitian requirements. These PIPs were reported and approved by the QAPI committee shortly before the facility’s alleged date of compliance following a prior abbreviated survey. However, the NHA stated that neither she nor the QAPI committee knew that the facility would not be in substantial compliance with the annual competencies, CNA education hours, and dietitian requirements by the alleged compliance date. The deficient QAPI process had the potential to affect the safety and quality of life of all 63 residents in the facility.
Noncompliant and Missing CPR Certifications Among Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff maintained current, compliant CPR certifications as required by regulation, facility policy, and job descriptions. During surveyor review of the CPR certification binder, one RN had no CPR documentation on file, and two nurses (an RN and an LPN) held CPR certifications obtained solely through online courses (LearnTastic and National CPR Foundation) without any in‑person, hands‑on training. The Human Resources Director stated that CPR documentation is kept in a separate binder from personnel files, acknowledged awareness that some staff needed updated certifications, and was unsure whether the RN with no documentation was among them. No additional CPR documentation for that RN was produced before survey exit. In telephone interviews, the RN and LPN with online certifications confirmed that their current CPR training was completed entirely online, without any in‑person, hands‑on component, and both reported they would be expected to assist if a code occurred during their shifts. The DON reported that at her previous facility, staff were required to complete CPR certification in person rather than online. The facility’s CPR policy requires that staff initiating CPR be certified in CPR/BLS and specifies that key clinical staff obtain or maintain American Red Cross or American Heart Association BLS/CPR certification. The facility’s nurse job description also lists current CPR certification as a required qualification. Regulation cited in the report requires that staff maintain current CPR certification for healthcare providers through a provider whose training includes a hands‑on session in a physical or virtual instructor‑led setting, which was not met for the two nurses with online‑only certifications and the RN with no documented certification.
Lack of Documented Nurse Competencies and Structured Orientation
Penalty
Summary
The facility failed to ensure that licensed nurses had documented knowledge, competencies, and skill sets to provide care that maximizes each resident’s well-being. Review of five randomly selected nurse personnel files (three RNs and two LPNs) showed no evidence of education, training, or competency assessments at hire or annually. The Human Resources Director stated that any annual competencies or education should be in the employee file and confirmed that none of the five nurses had formal competencies completed during the new hire process or yearly, and that there were no required online or hands-on training programs in place at the time. Staff interviews further demonstrated the lack of a functioning competency program. A long-term RN reported working in the building for 22 years and stated that monthly educational in-services had stopped about two years prior and that he did not recall any formal yearly competency evaluations. Another RN described his new hire orientation as meeting with HR, reviewing policies/handbook, and about 1.5 days of job shadowing with a unit manager, with no hands-on training, formal education, or skill competency/checklist that he could recall. The DON reported that, to her knowledge, there had been no annual competencies in place and that prior new hire orientation consisted only of verbal information from HR and informal floor orientation, despite a written facility policy requiring structured orientation, assignment of a preceptor, documented competency evaluation forms, and maintenance of these forms in personnel files.
Failure to Provide Required CNA Training and Competency Evaluations
Penalty
Summary
The facility failed to maintain required in-service training and competency evaluations for CNAs, including dementia care and abuse prevention education. Review of five randomly selected CNA employee files (R, S, T, U, and A) showed no documentation of annual or new hire education, training, or competencies. The Human Resources Director stated that any annual competencies or education should be kept in each employee file and confirmed that none of the five CNAs had formal competencies or in-services completed during the new hire process or annually, and that there was no required online or hands-on training in place at the time. A CNA reported she had not received any formal competency evaluation or skills check at this facility, though she had at other facilities. The DON reported that, to her knowledge, there had been no system for annual competencies and that, until approximately two weeks prior, new hire orientation consisted only of verbal information from HR and an informal orientation with staff on the floor. No residents or specific clinical conditions were mentioned in relation to this deficiency.
Unqualified Staff Directing the Activities Program
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the activities program was directed by a qualified professional as required. During an interview, the Activities Director (AD) reported she had been in the role since December 2025 and stated she was not certified but was currently taking a class. In a follow-up interview, she explained that the previous administrator had offered her the Activities Director position and that she believed she met the job description qualifications because she was eligible for certification. She further reported that she was responsible for scheduling activities, implementing or delegating implementation of programs, monitoring residents’ responses to the programs, reviewing and evaluating whether activities met residents’ assessed needs, and making revisions as necessary. A review of the facility’s Activities Director job description showed that the position required the activities program to be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered if applicable, and who either is eligible for certification by a recognized accrediting body on or after October 1, 1990, has 2 years of experience in a social or recreational program within the last 5 years (with one year full-time in a therapeutic activities program), is a qualified occupational therapist or occupational therapy assistant, or has completed a state-approved training course. In an interview with the Nursing Home Administrator (NHA), after reviewing the job description, the NHA stated that based on the job description and her understanding of the regulation, the current AD was not qualified for the position.
Failure to Prevent Resident-to-Resident Physical and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident-to-resident physical and verbal abuse, resulting in one resident sustaining a facial injury and being subjected to threats by another resident. One male resident with traumatic brain injury, intermittent explosive disorder, psychological disorder, anxiety, and depression, and who was cognitively intact per a BIM score of 13, was self-propelling in his wheelchair in the main dining room during a resident activity. Another male resident with vascular dementia, irritability and anger, anxiety, and depression, also cognitively intact per a BIM score of 15, was in his wheelchair in the same area. According to the then–NHA’s witness statement, the first resident’s wheelchair bumped into the second resident’s wheelchair, after which the second resident swung back with his right arm and closed fist, striking the first resident on the right side of the face near the mouth. The first resident yelled out and was later observed to have a small open area on his bottom lip and blood in his mouth. The NHA reported that when he questioned the second resident about the incident, the resident stated that the other resident had run into his chair and that this was a good reason to hit him. The second resident also used explicit language and laughed about the situation. The facility’s 5-day investigation substantiated that abuse had occurred and that the first resident sustained an injury. At the time of the surveyor’s later observations and interviews, both residents appeared calm, reported feeling safe at the facility, and denied fear of others, but the cited deficiency centers on the earlier failure to prevent the resident-to-resident altercation that resulted in physical contact, a facial laceration, and verbal threats.
Failure to Readmit Hospitalized Resident and Follow Bed-Hold/Discharge Policies
Penalty
Summary
The deficiency involves the facility’s failure to allow a hospitalized resident to return to the facility at the first available bed and failure to follow required transfer, bed-hold, and discharge policies and procedures. The resident was an adult male with a progressive neurologic disorder, dementia with agitation, and an adjustment disorder with anxiety. His MDS showed a BIM score of 9, indicating moderately impaired decision-making, with limited documented behavioral symptoms prior to the events in question. He had been admitted to the facility in October and was later transferred to the hospital due to exit-seeking behavior and difficulty with redirection, but his care plans and orders were discontinued on 1/19/26 even though he had not been formally discharged through the required process. Prior to the final hospital transfer, the resident had episodes of exit-seeking and was placed on 1:1 supervision for safety. Documentation on 11/14/25 showed that he was readmitted from a local hospital with a diagnosis of dementia and placed on 1:1 supervision due to exit-seeking behavior. An elopement evaluation on 11/14/25 documented wandering behaviors that were likely to affect his safety, and he was identified as recently admitted and not yet accepting the situation. Subsequent nursing notes from 11/14/25 through 12/27/25 reflected no documented behaviors and described him as pleasant, cooperative, and continuing on 1:1 supervision. On 12/27/25 and 12/28/25, three notes documented increased agitation, exit-seeking, and physical aggression toward staff, and the provider was contacted after failed attempts at redirection. The resident was then transferred to the hospital on 12/28/25. After this transfer, the facility did not provide evidence that a required Transfer Notice or Bed Hold policy information was given to the resident or his representative. Interviews with the SW and DON confirmed uncertainty or lack of knowledge about whether these notices were provided, despite facility policy requiring written information before transfer and permitting residents to return after hospitalization. The DON acknowledged that the resident had been gone longer than the 10‑day bed-hold period and that the guardian had declined to pay to hold the bed, but also confirmed that the facility census was 62 with at least 72 beds available and that the resident’s prior bed had remained empty from 12/28/25 to the survey date. The BD stated that the clinical team decided the resident would not be allowed to return due to aggressive behaviors and that his bed had been “spoken for,” while also acknowledging that the only male bed on the unsecured unit was promised to another resident after the psychiatric hospital had already been told there were no beds available for the resident. The psychiatric hospital case worker reported contacting the facility on 1/19/26 to inform them the resident was ready to discharge back, less than 30 days after admission, and was told there were no beds available and that a list of other placement options would be provided. The Ombudsman reported prior communication with the facility about concerns regarding an appropriate discharge for the resident and stated that the resident had reported being threatened with not being allowed to return, even though no involuntary discharge process had been initiated. The facility’s own Bed Hold and Return to Facility policy required that residents be allowed to return to their previous room if available, or to the first available semi-private bed, and that if the facility determined a resident could not return, it must comply with transfer and discharge requirements. The surveyor observed multiple open beds, including the resident’s prior room being empty, and the bed board showed additional available beds, some reserved for Medicare and others offline, while the resident, a Medicaid recipient, remained hospitalized without being readmitted. These actions and omissions resulted in the facility failing to permit the resident’s return at the first available bed and failing to implement required discharge policies and procedures, creating increased likelihood of anxiety, stress, and uncertainty about placement for the resident.
Failure to Provide Written Transfer Notice and Bed-Hold Policy at Hospitalization
Penalty
Summary
The facility failed to provide required written notification of transfer and bed-hold policy to a resident and/or the resident’s representative at the time of a hospital transfer. The resident was an older male with diagnoses including a progressive neurologic disorder, dementia with agitation, and an adjustment disorder with anxiety. His MDS showed a BIM score of 9, indicating moderately impaired decision-making ability, and documented limited behavioral symptoms such as verbal behaviors toward others and other behaviors toward self on some days. A complaint filed with the State of Michigan alleged the facility refused to readmit the resident after a hospital admission. Review of the electronic medical record showed the resident was transferred to the hospital and that his orders and care plans were discontinued on a later date, and he was no longer a current resident. Nurse progress notes from the days immediately preceding the transfer documented increased agitation, exit-seeking behaviors, and physical aggression toward staff, with a provider contacted after failed attempts at redirection. However, record review revealed no evidence that a required written Transfer Notice or the facility’s bed-hold policy was provided to the resident or the responsible party following the transfer to the hospital. During interviews, the DON, who had been at the facility for about one month, confirmed the resident had been transferred and had not returned, stated that both a Transfer Notice and bed-hold information should have been provided and documented in the medical record, and reported being unable to locate any evidence that the responsible party was notified in writing of the transfer or bed-hold policy.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and dementia from sexual abuse by another resident with moderate cognitive impairment and Alzheimer's. The first incident occurred when a resident with dementia, who was unable to consent to sexual relations, was found in another resident's room with her shirt lifted and her breasts exposed, while the other resident was touching her breasts. This was observed by a CNA, who did not immediately intervene but instead left to notify an RN. When staff returned, the resident was still in the room and was then redirected out. The CNA later reported she was unsure of what to do at the time and received education from the RN about appropriate intervention. The resident's care plan indicated she could not consent to sexual activity, and the other resident's care plan noted a history of sexually inappropriate behavior. A second incident occurred when the same two residents were observed in the main dining room, with the resident with Alzheimer's rubbing the other resident's leg and buttocks over her clothing. Maintenance staff separated the residents, and an LPN was notified. The facility had been aware of the previous incident but did not prevent further contact between the two residents, resulting in repeated inappropriate interactions. Both residents had significant cognitive impairments, and the facility failed to implement effective measures to prevent further abuse, as evidenced by the recurrence of inappropriate contact.
Unsafe Hot Water Temperatures, Inadequate Fall Response, and Unsupervised Tobacco Use
Penalty
Summary
The facility failed to ensure that hot water temperatures in resident care areas were maintained within the safe and comfortable range of 100-120 degrees Fahrenheit. Multiple observations revealed that water temperatures in several resident rooms, including those occupied by individuals with severe and moderate cognitive impairment, were significantly above the recommended maximum, with some readings as high as 152.6 degrees Fahrenheit. The facility's maintenance logs did not reflect these excessive temperatures, and there were missing documentation sheets for the required monitoring period. Staff interviews indicated inconsistent practices in temperature monitoring and a lack of immediate recognition or reporting of hazardous water temperatures. Additionally, the facility did not adequately investigate or implement interventions following multiple falls experienced by a resident with severe cognitive impairment and a history of wandering and difficulty walking. Despite several documented falls, including one resulting in a head laceration and hospitalization, the care plan was not updated with new interventions, and incident reports or investigations were not consistently completed. Observations further showed that safety measures, such as ensuring the resident's walker and call light were within reach, were not reliably maintained. The facility also failed to prevent potential accidents by allowing a visually impaired resident unsupervised access to chewing tobacco and a spit cup in his room. Staff were aware of the resident's use of chewing tobacco, but there was no specific policy addressing its use, and the tobacco was left accessible at the bedside. Interviews with staff and family confirmed that the resident had been using chewing tobacco in his room for an extended period, and the facility's smoking policy did not address smokeless tobacco products or their safe storage and supervision.
Plan Of Correction
F689 - Free of Accidents/Hazards/Supervision/Devices DPS A: 1. 100% of community residents were assessed by the Director of Nursing and designees on 05/06/25 to ensure no negative effects related to water temperatures. Resident showers were taken offline to ensure safety of water temperatures, to include bed baths. The water temperature was adjusted to ensure temperatures within regulatory standard. The Maintenance Director and designee conducted a 100% community audit of resident area water sources to ensure appropriate temperatures per regulatory guidance. 2. The Administrator reviewed the policy and procedure related to Safe Water Temperatures on 05/06/2025 with changes completed as necessary. Community staff will be educated on the policy for Safe Water Temperatures, with all staff completed or removed from the schedule by 05/09/25. 3. The Maintenance Director or designee will conduct an audit of resident room water temperatures daily, on both shifts for seven days, then twice weekly thereafter to ensure water temps meet regulatory standards. Results of the audits will be brought to the Quality Assurance Performance Improvement Committee for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 06.20.2025 DPS B: Element #1: R58 was assessed by the Director of Nursing or designee to ensure incident report, care plan, and interventions are updated to reflect resident current status. R38 was assessed by the Director of Nursing or designee to ensure no adverse effects related to their use of chewing tobacco. Behavior was care-planned and interventions put in place to prevent recurrence. Element #2: The Director of Nursing and/or designee conducted a 100% audit of residents with falls in the last 30 days to ensure documentation is complete to include updated care plans and interventions. The Director of Nursing and/or designee will conduct a 100% sweep of resident rooms to ensure no tobacco products are improperly stored. Element #3: The Administrator reviewed the policies related to Fall Prevention Program and Resident Smokeless Tobacco and revised as necessary. Community staff were provided education regarding the fall prevention program and smokeless tobacco. Element #4: The Director of Nursing and/or designee will conduct an audit of 10 residents weekly for 12 weeks to ensure appropriate documentation, care planning and interventions related to resident incidents. The Director of Nursing and/or designee will conduct an audit of 10 resident rooms weekly to ensure no tobacco products are stored inappropriately. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Removal Plan
- Community residents are assessed by the Director of Nursing and designees to ensure no negative effects related to water temperatures. Resident showers are taken offline to ensure safety of water temperatures, including bed baths.
- The water temperature is adjusted to ensure temperatures within regulatory standard. The Maintenance Director and designee conduct a community audit of resident area water sources to ensure appropriate temperatures per regulatory guidance.
- The Administrator reviews the policy and procedure related to Safe Water Temperatures with changes completed as necessary. Community staff are educated on the policy for Safe Water Temperatures, with all staff completed or removed from the schedule.
- The Maintenance Director or designee conducts an audit of resident room water temperatures daily, on both shifts for seven days, then twice weekly thereafter to ensure water temps meet regulatory standards. Results of the audits are brought to the Quality Assurance Performance Improvement Committee for review. Any changes to the auditing process are determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance.
Failure to Update Wound Care Orders and Implement Pressure Ulcer Prevention
Penalty
Summary
The facility failed to implement and update physician orders, accurately assess and document pressure ulcers, ensure pressure ulcer prevention interventions were implemented, adequately assess and treat pain prior to wound care, and prevent the development of pressure ulcers for two residents. For one resident with severe cognitive impairment, muscle weakness, contractures, and a history of pressure-induced deep tissue injury, the facility did not update physician orders to reflect current wound care recommendations from an outside wound care provider. The resident's wound care was performed according to outdated orders, and the resident was observed without required pressure-relieving boots on multiple occasions. Pain was not assessed or treated prior to wound care, and as-needed pain medication was only administered after the procedure. Another resident, dependent on a wheelchair and with diagnoses including vascular dementia and diabetes, developed two facility-acquired stage II pressure ulcers. Documentation of the wounds was incomplete, lacking descriptions of the wound bed. The resident was repeatedly observed seated in a wheelchair without a pressure-relieving cushion, despite recommendations from a nurse practitioner for a specialty cushion and a low air loss mattress. Staff confirmed that the resident sometimes went weeks without a wheelchair cushion. The care plan did not reflect the presence of pressure ulcers or include interventions for pressure relief. Both cases demonstrate failures in following physician and wound care provider recommendations, maintaining accurate and updated documentation, implementing necessary pressure ulcer prevention and treatment interventions, and ensuring pain management during wound care. These deficiencies resulted in worsening of a pressure ulcer, unrelieved pain during wound care, and an increased risk of further skin breakdown for the affected residents.
Plan Of Correction
F686 - Treatment/Services to Prevent/Heal Pressure Ulcers Element #1 R11's Pressure ulcer was reassessed by the Wound NP. Wound measurements were updated, appropriate treatment orders were obtained, and pain management interventions were implemented prior to wound care. R20's new pressure ulcer was staged, documented, and entered into the treatment administration record. Physician orders were obtained and implemented. Preventive interventions were put in place. Element #2 The Director of Nursing and/or designee conducted a 100% audit of residents with existing pressure ulcers and residents at high risk for skin breakdown. The audit included verification of physician orders, review of treatment records, and assessment of pressure-relieving interventions. Pain assessments during wound care were also reviewed to identify any documentation or treatment gaps. Element #3 The Administrator reviewed the policy on Pressure Injury Prevention and revised as necessary. Licensed Nurses were provided education on timely and accurate wound assessment and staging, implementation and documentation of pressure ulcer prevention interventions, communication of wound care orders, and ensuring pain management is in place before treatment. Element #4 The Director of Nursing or designee will conduct weekly audits of all residents with pressure ulcers and those identified as high-risk (Braden score =18) for 12 weeks to ensure accurate documentation, orders, and treatment. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Deficiencies in Food Service Sanitation and Date Marking
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations, including failures in cleaning and maintaining food service equipment and improper date marking of potentially hazardous ready-to-eat food products. Specifically, opened containers of milk were found in coolers without effective open or discard dates, despite manufacturer use-by dates being present. Additionally, non-pasteurized shell eggs were stored in the cooler and used for resident meals, contrary to food code requirements for pasteurization. Several pieces of kitchen equipment, such as a can opener, convection oven, coffee machine, and microwave, were found with accumulated and encrusted food residue, indicating inadequate cleaning practices. The microwave oven's interior door mesh screen was also damaged, posing a potential safety issue. The dish machine's final rinse cycle was operating at a water pressure above the recommended range, and the walk-in cooler had flooring and door maintenance issues, including loose anti-skid strips and a malfunctioning automatic door closer. Record reviews of facility policies revealed that the facility had established procedures for sanitation, cleaning, and date marking, which were not consistently followed as evidenced by the observations. These failures affected all residents who consumed food from the facility, increasing the likelihood of cross-contamination and foodborne illness, as noted in the survey findings.
Plan Of Correction
F812 – Food Procurement, Store/Prepare/Serve – Sanitary Element #1: Dining staff immediately corrected the following concerns: - Milk observed without proper date-marking was disposed of. - Non-pasteurized eggs were discarded. - The can opener was deep cleaned. - The oven was deep cleaned. - The coffee machine was deep cleaned. - The microwave was replaced. - Dish machine will be repaired to ensure PSI within manufacturer recommended guidelines by the compliance date. - Walk-in cooler will be repaired to ensure the door to the walk-in cooler closes to a positive latch by the compliance date. - Maintenance replaced the anti-slip strips in the walk-in cooler. Element #2: The Dietary Manager conducted a full sanitation inspection of food storage and preparation areas to identify and correct additional risks. Element #3: The Administrator reviewed the policy on Date Marking for Food Safety, and Sanitation Inspection. Dining Services staff were provided re-education on the policies for date marking and sanitation. Element #4: The Dietary Manager and/or designee will perform kitchen sanitation inspections 3x weekly for 12 weeks to ensure compliance with food safety and sanitation protocols. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Maintain Effective QAPI Program for Resident Safety Concerns
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by its lack of identification and follow-up on critical areas requiring improvement. During the survey, an Immediate Jeopardy concern was identified regarding hot water temperatures, which the facility was unaware of. Additionally, there was a concern about the accommodation of resident needs related to call light accessibility. Resident council meeting minutes documented a complaint about the absence of hot water in resident rooms, to which the facility responded by stating they would check hot water temperatures weekly. However, QAPI meeting minutes showed no further discussion or documentation of weekly hot water temperature checks, nor were any logs available. In an interview, the administrator could not confirm whether a QAPI meeting had been held for the previous month and was unaware of any QAPI discussions or performance improvement plans addressing water temperature issues or call light accessibility.
Plan Of Correction
F865 – QAPI Program/Plan, Disclosure/Good Faith Attempt Element #1: The facility’s QAPI plan was updated on 5/27/2025 to include specific goals and performance indicators. The QAPI committee was re-structured to ensure monthly meetings with effective data analysis and prioritization of performance improvement projects. Element #2: The Administrator initiated a QAPI participation review to ensure all department heads are submitting routine data and quality indicators for review and action planning. Element #3: The Administrator reviewed the policy on Quality Assurance Performance Improvement and revised as necessary. Community staff were provided education on QAPI. Element #4: The Administrator and/or designee will audit QAPI meeting minutes for 3 months to ensure compliance with active, data-driven performance improvement projects. QAPI effectiveness will also be evaluated monthly by ownership. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Maintain Clean and Safe Physical Environment
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 61 residents. During environmental tours of both common areas and resident rooms, surveyors observed multiple deficiencies, including loose grab bars, damaged and soiled chair cushions, missing atmospheric vacuum breakers on shower wands, and soiled janitor closets and ventilation grills. Overhead light assemblies were found to be non-functional or soiled with dust, dirt, and dead insects. Several areas, such as the dining room and storage rooms, had missing or damaged flooring and light covers, and hand sinks were noted to be draining slowly. In resident rooms, numerous issues were identified, such as cracked or broken light covers, non-functional lights, missing pull string extensions, loose or missing commode seats and caulking, and heavily soiled ventilation grills. Human fecal material was observed on drywall surfaces and adjacent to restroom shower stalls in some rooms. Additional problems included ill-mounted doors, missing thermostat covers, and loose enable bars, all of which contributed to an environment that was not adequately maintained or cleaned. Record reviews revealed that the facility had policies and procedures in place for maintenance inspections, preventative maintenance, and routine cleaning and disinfection. However, the review of work orders for the previous 60 days showed no documentation of the identified maintenance concerns, indicating a lack of follow-through on the facility's stated policies. These findings collectively demonstrate a failure to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.
Plan Of Correction
F921 – Safe/Functional/Sanitary/Comfortable Environment Element #1: Environmental deficiencies listed below will be addressed: - The wall-mounted grab bars in therapy near the scale were repaired. - Damaged chairs in therapy were replaced. - Shower wand assemblies were equipped with an atmospheric vacuum breaker. - The floor and mop sink basin in the janitor's closet were cleaned. - Return air exhaust ventilation grills were cleaned in the nurse station restroom, the soiled utility room, the activities storage room, Rm 124 restroom, Rm 130 restroom, Rm 131 restroom. - Overhead light assemblies were repaired and/or cleaned in the lift storage room, the main dining room, Rm 102 bed 2, Rm 117 bed 1, Rm 122 bed 1, Rm 123 bed 1, Rm 128 bed 1, Rm 129 bed 2, Rm 135 bed, Rm 135 restroom, and Rm 143 entrance light. - Beauty shop hand sink basins were repaired to ensure proper drainage. - Flooring was repaired in the storage room. - Commode base caulking was repaired in Rm 101, Rm 102, Rm 111, Rm 122, Rm 124, Rm 128, Rm 130, Rm 131, Rm 135, and Rm 143. - Rm 101: drywall was cleaned above the waste receptacle. - Rm 117: Restroom door was repaired to ensure proper mounting and close to a positive latch. - Rm 122: The wall-mounted thermostat, and restroom faucet assembly were repaired. - Rm 123: The commode seat and cove base were repaired. - Rm 127: Bed 2 metal frame was assessed and repaired. - Rm 128: The commode seat was repaired. - Rm 133: The commode support and seat were repaired. Restroom interior door was repaired. - Rm 135: Bed 2 enabler bar and restroom toilet paper holder were repaired. The restroom was cleaned. Element #2: The Maintenance Director initiated a full facility walkthrough to identify and resolve any additional safety, sanitation, or functional issues. Element #3: The Administrator reviewed the policy on Resident Environmental Quality, and Routine Cleaning and Disinfection, and revised as necessary. Community staff were re-educated on the policies. Element #4: The Maintenance Director and/or designee will conduct weekly environmental rounds for 12 weeks to ensure compliance with the regulation. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Limit and Document PRN Psychotropic Medication Use
Penalty
Summary
A deficiency occurred when a resident with major depressive disorder and early-onset Alzheimer's disease, who was severely cognitively impaired, was prescribed Lorazepam (Ativan), an antianxiety medication, on an as-needed (PRN) basis. The physician's order allowed for administration of 0.5 mg every 4 hours as needed for anxiety. The order was initiated and remained active beyond the federally mandated 14-day limit for PRN psychotropic medications without documented physician rationale for extension or evidence of a required evaluation for continued use. Record review and interview with the Director of Nursing confirmed that the PRN Ativan order was not discontinued after 14 days, nor was there a documented reassessment or justification for its ongoing use. This failure to comply with federal regulations regarding the limitation and documentation of PRN psychotropic medication orders resulted in the cited deficiency.
Plan Of Correction
Element #4: The Director of Nursing and/or designee will review all new psychotropic PRN orders weekly for 12 weeks to verify duration limits and appropriate physician documentation. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to six out of fifteen residents, as required by their own policy. Multiple residents were observed without call lights within reach, with some call lights either wrapped around outlet boxes, behind headboards, or on the floor. In one case, a resident had been using a bell for about a year to call for assistance because the call light was not functional and not within reach. The bell was not effective in alerting staff, as it could barely be heard at the nurse's station. Another resident was found with a call light cord behind the headboard, out of reach, and no mechanism was in place to prevent the cord from falling out of reach. Several residents expressed frustration or resorted to yelling for help due to the inaccessibility of their call lights. Staff interviews confirmed that some residents had been without accessible or functional call lights for extended periods, and in one instance, a resident had been using an alternative signaling device for about a year. Observations also revealed that some residents were unsure of how to use the call light system or mistook other devices, such as bed or TV remotes, for call lights. The facility's policy requires staff to ensure call lights are within reach and secured as needed, but this was not consistently followed, resulting in residents being unable to reliably summon assistance when needed.
Plan Of Correction
F558 – Reasonable Accommodations of Needs/Preferences Element #1: The Maintenance Director and designee conducted rounds to ensure that call lights were accessible to all cited residents (R4, R7, R23, R26, R46, R134). Faulty equipment was replaced or repaired, cords were secured properly, and staff were directed to check accessibility at each point of care. Element #2: A facility-wide sweep was conducted by the Maintenance Director and designee to assess call light accessibility for all residents. Maintenance documented and addressed any additional concerns observed. Element #3: The Administrator reviewed the Call Light Accessibility policy and updated as necessary. Community staff were re-educated regarding call light accessibility, function, and response. Element #4: The Director of Nursing and/or designee will conduct random weekly audits of 10 residents for 12 weeks to ensure call lights are within reach and functioning appropriately. Any concerns will be immediately corrected. Results of the audits will be brought to the QAPI Committee monthly for review. The QAPI Committee will be responsible to determine changes to the auditing process. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Follow Physician Orders and Provide Proper Assessment and Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for four residents. For one resident with heart failure and chronic respiratory failure, staff did not follow a physician's order requiring the head of bed to remain elevated due to shortness of breath. The resident was observed lying flat in bed on two occasions, and a registered nurse confirmed this was not in accordance with the order. Another resident with vascular dementia and diabetes experienced new or worsening edema after a hospital visit, with orders for daily diuretic therapy. Despite this, the facility did not assess or monitor the resident's edema, as confirmed by the Director of Nursing, who acknowledged the lack of documentation for daily weights, lung sounds, vital signs, or edema assessment since the resident's return from the hospital. A third resident with a long-term indwelling Foley catheter developed a significant penile injury, described as a split extending the length of the penis head. The catheter was not consistently secured with a device, and there was no documentation of resident refusal, education, or interventions to prevent catheter-related injury. The care plan lacked interventions for catheter care or securement, and staff interviews revealed inconsistent use of securing devices. Additionally, a fourth resident admitted with abdominal wounds did not receive wound care orders as specified in hospital discharge instructions. The required negative pressure wound therapy and specific dressing changes were not implemented or documented, and nursing staff could not confirm what treatments were provided prior to the resident's transfer back to the hospital.
Plan Of Correction
F684 – Quality of Care Element #1 R20: Physician orders were reviewed and reconciled. Orders were implemented as appropriate. R11: A head-to-toe assessment was completed, and the resident's edema was evaluated and documented. The care plan was updated, and physician notification occurred as necessary. R38: The urinary catheter was properly secured. R67: Wound care orders were implemented, and a complete skin assessment was completed. Element #2: The Director of Nursing and/or designee conducted an audit of residents newly admitted within the last 30 days, residents with physician orders involving wound care, indwelling catheters, or fluid retention diagnoses. Each resident was reviewed for missed orders, unaddressed edema, improper catheter care, and delayed implementation of hospital orders. Element #3: The policies on Admission Orders and Catheter Care were reviewed by the Administrator and revised as necessary. Licensed Nurses and Department Managers were provided education on the aforementioned policies to ensure compliance with orders. Element #4: The Director of Nursing or designee will conduct weekly audits of 10 randomly selected charts for 12 weeks to ensure appropriate orders are in place and being followed per resident record. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Insufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights and unmet care needs for multiple residents. One resident, who was cognitively intact and had chronic obstructive pulmonary disease and diabetes, reported call light response times ranging from 35 minutes to one hour and 45 minutes, with delays occurring on any shift. Another resident with hemiplegia and hemiparesis following a stroke reported having to remain in soiled briefs for hours, particularly during the day shift, and noted that more than one staff member was needed to assist with changing. A third resident, also cognitively intact and requiring assistance with personal care, reported waiting up to an hour for call light responses and that staff would sometimes acknowledge the call but not return to provide assistance, especially when the resident wanted to get out of bed in the morning. Staff interviews confirmed that the facility experienced short staffing, particularly on weekends and at least three times in the prior three months. The scheduler indicated that staffing was based on census and acuity, and that some residents required more staff time, which contributed to delays. During a Resident Council meeting, all residents present reported insufficient staffing, with specific concerns about long wait times for call light responses, especially at night and after 6pm. Residents also reported that staff sometimes turned off call lights without addressing their needs.
Plan Of Correction
F725 – Sufficient Nursing Staff Element #1 Residents #2, #25, and #37 were individually assessed to ensure their current needs were being met without delay. Their care plans were reviewed and updated as needed to include prompt response protocols and individualized care interventions. Element #2 A facility-wide audit will be completed by the Director of Nursing and/or designee to evaluate call light response times and overall resident satisfaction with care timeliness. Resident Council concerns were formally reviewed during the June meeting and integrated into the action plan. Element #3 The Administrator reviewed the policy on Call Light Accessibility and Timely Response, and revised as necessary. Community staff were provided education on the policy to include timely response standards and the importance of resident-centered care. Element #4 The Director of Nursing and/or designee will conduct random call light response audits for 10 residents weekly for 12 weeks. In addition, 5 resident interviews regarding call light responsiveness and care timeliness will be completed weekly by Social Services. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Complete Monthly Pharmacist Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed monthly drug regimen reviews, including review of the medical chart, for five residents. For several residents, including those with complex medical conditions such as COPD, diabetes, pressure ulcers, dementia, and major depressive disorder, there was no documented evidence that pharmacy medication regimen reviews were completed for multiple months, including March 2025 and several months in 2024. The absence of these reviews was confirmed through both record review and staff interviews, where the Director of Nursing (DON) was unable to provide the required documentation and acknowledged that if the reviews were not in the medical record, they had not been completed. Further interviews revealed confusion regarding the responsibility for conducting the monthly medication regimen reviews. The facility's contracted pharmacy reported that they only provided medications and reviewed them upon nursing staff request, while a third-party pharmacist was said to be responsible for the monthly reviews. However, there was no evidence in the residents' records that these reviews had occurred. This lack of documentation and follow-through resulted in the facility not meeting regulatory requirements for monthly pharmacist review of resident medication regimens.
Plan Of Correction
F756 – Drug Regimen Review, Report Irregular; Act On Element #1: The pharmacy consultant reviewed the resident medication regimen for R9, R33, R40, R41, and submitted recommendations to the attending physician. The physician acknowledged the recommendations and documented follow-up actions. Element #2: An audit of pharmacy consultant reports from the last 60 days was initiated to verify timely review, physician acknowledgment, and appropriate follow-up on identified concerns. Element #3: The Medication Regimen Review policy was reviewed by the Administrator and revised as necessary. Licensed Nurses and the Provider group were re-educated on the policy and procedure. Element #4: The Director of Nursing and/or designee will audit 5 resident records per week for 12 weeks to ensure all pharmacist recommendations are documented and acted upon. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Medication Labeling, Storage, and Administration Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the labeling and storage of medications. During a medication administration, an RN was seen using an iron pill bottle that lacked a manufacturer's expiration date, with only a handwritten date indicating when the bottle was opened. The RN was unaware of the significance of the handwritten date and could not determine the expiration date of the iron pills, yet proceeded to administer the medication and returned the bottle to the medication cart for future use. Additionally, an LPN was observed improperly disposing of two pills by placing them in a medication cup with pudding, then removing and discarding them in an open, unlidded garbage can attached to the medication cart. The pills remained visible and accessible, and the medication cart was left unattended in a room with ambulatory residents. The LPN was unfamiliar with the facility's policy for disposing of non-controlled substances. Further deficiencies were identified in medication administration practices. One resident was found to have a medication cup with four pills left on their overbed table, while the resident was not present in the room. The LPN responsible for administering the medications admitted to leaving the medications at the bedside and not observing the resident consume them, contrary to facility policy. The DON confirmed that nurses are required to observe residents taking their medications before documenting administration. Another incident involved a resident who possessed marijuana gummies in their room and had shared at least one gummy with another resident. The resident admitted to having the gummies and eventually surrendered an opened bag to staff, who placed it in the narcotic box of the medication cart. The DON and ADON were unaware of the incident and could not provide information on the facility's policy regarding cannabis products. The facility's policy on cannabidiol (CBD) indicated that such products should be administered by licensed nurses with a physician's order and treated as controlled substances, with strict documentation and counting procedures.
Plan Of Correction
F761 – Label/Store Drugs & Biologicals Element #1: Resident #35 and #36 were assessed by the Director of Nursing or Designee to ensure no lasting effects related to the improper storage of medications. Element #2: A full-house medication storage audit was conducted across units to identify and correct any additional labeling or storage violations. Element #3: The Administrator reviewed the policy on Medication Storage, and Destruction of Unused Drugs and updated as necessary. Licensed Nurses will be re-educated on the policy and procedures for Medication Storage and the Destruction of Unused Drugs. Element #4: The Director of Nursing and/or designee will conduct weekly inspections of the medication storage areas and medication carts to ensure compliance with storage and destruction. The Social Service Director and/or designee will conduct a weekly sweep of 10 resident rooms to ensure residents without approved assessments and equipment are not self-administering. Compliance Date: 6/20/2025
Failure to Consistently Offer Bedtime Snacks to Residents
Penalty
Summary
The facility failed to consistently offer bedtime snacks to residents, as evidenced by interviews and record reviews. During a confidential Resident Council meeting, nine out of ten residents reported that snacks were not offered at bedtime and expressed a desire for them. Residents stated that snacks were not provided every night, and when they were, the variety was limited, with most options being peanut butter sandwiches. Several residents agreed that the previous kitchen staff were more consistent in offering snacks. Resident Council meeting minutes from previous months also documented ongoing concerns about not receiving snacks at night. An interview with a dietary cook revealed that dietary staff deliver a tray of snacks to each unit daily, typically around dinner time, and that nursing staff are responsible for offering these snacks to residents at night. The cook noted that sometimes the snack trays are returned with most items untouched, suggesting that snacks may not have been offered. Facility policy requires that residents be offered and served a nourishing snack at bedtime daily, with dietary staff delivering snacks to the nurses' stations and nursing staff responsible for serving them to residents.
Plan Of Correction
F809 - Frequency of Meals/Snacks at Bedtime Element #1: The Administrator attended Resident Council on 06.04.2025 to discuss the plan for HS Snack delivery, and Food Committee was held with residents immediately afterward. Element #2: The Dietary Manager will conduct a full-house audit to ensure that all residents are offered an HS snack whether based on physician order or resident preference. Element #3: The Administrator reviewed the policy on Offering / Serving Bedtime Snacks, and revised as necessary. Community staff will be provided re-education on the policy and procedure. Element #4: The Dining Services Manager and/or designee will audit the delivery and documentation of snacks on night shift three times per week for 12 weeks. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Maintain Resident Call System in Bathrooms and Bathing Areas
Penalty
Summary
The facility failed to effectively maintain the resident call system, impacting 61 residents. Observations showed that while the call system was functioning in several resident rooms on the South Unit, an interview with a resident indicated dissatisfaction with the current call system, expressing a preference for the previous system. The facility's policy requires that each resident's bedside, toilet, and bathing area be equipped with a call light, and that staff and residents be educated on its use. The policy also mandates immediate reporting and alternative solutions if the call system is not functioning. Despite these requirements, a review of the facility's maintenance work order system and the Direct Supply TELS Work Orders for the past 60 days revealed no specific entries related to the resident call system. This lack of documentation suggests that issues with the call system may not have been reported or addressed as required by facility policy, increasing the likelihood of delayed emergency response or negative outcomes for residents.
Plan Of Correction
F919 - Resident Call System Element #1: The Maintenance Department repaired the cited inoperable call bell systems and ensured that the documented resident call lights were functioning properly. Element #2: The Maintenance Director and/or designee will conduct a 100% audit of call systems to ensure each resident has a call light that is appropriate for their current status and properly functioning. Element #3: The Administrator reviewed the policy on Call Lights and revised as necessary. Community staff were re-educated on the policy to include reporting of inoperable equipment. Element #4: The Maintenance Director and/or designee will perform a weekly facility-wide call system inspection for 12 weeks and log all maintenance responses. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Ensure Resident Dignity and Respect Due to Inadequate Response to Verbal Abuse
Penalty
Summary
A resident with legal blindness, muscle weakness, and cognitive intactness was admitted to the facility and reported being verbally abused by his roommate, who called him derogatory names. The resident stated that staff were aware of the situation and had witnessed the name-calling. Interviews with the roommate confirmed the use of offensive language, and staff interviews corroborated that the behavior had been observed previously. The affected resident also expressed fear of his roommate due to these interactions. Despite multiple reports and observations of inappropriate behavior by the roommate, the care plan for the roommate did not include any interventions for this behavior until several days after the incidents were reported and observed. The facility's policy requires residents to be treated with respect and dignity and to have a safe and comfortable environment, but this was not upheld in this case, as evidenced by the lack of timely intervention and care planning.
Plan Of Correction
F550 – Resident Rights/Exercise of Rights Element #1: Resident #38 and #35 were assessed by the Director of Nursing and/or designee to ensure satisfaction with the room change conducted and psychosocial support provided. Element #2: A facility-wide audit will be completed to identify any additional residents reporting verbal conflicts or roommate issues. All care plans will be updated accordingly. Element #3: The Resident Rights policy was reviewed and updated as necessary by the Administrator. Community staff were re-educated on the Resident Rights policy and the Grievance process. Element #4: The Social Services Director or designee will conduct random audits of 5 resident pairs weekly for 12 weeks to assess interpersonal compatibility and care plan interventions related to dignity and resident rights. Audit findings will be reported monthly to the QAPI Committee for review and corrective follow-up. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document the required informed consent from the guardians of two residents prior to administering psychotropic medications. In the first case, a resident with major depressive disorder and early-onset Alzheimer's disease, who was severely cognitively impaired as indicated by a BIMS score of 0, was prescribed Lorazepam (Ativan) for anxiety. The resident's family member, who is also the guardian, reported not being informed about the new medication order. Review of the medical record confirmed that although a request for consent was initiated, a signed consent was not obtained or available for review at the time of the survey. In the second case, another resident with dementia, who was not interviewable, was prescribed Zyprexa (an antipsychotic). Similarly, there was no signed consent obtained or available for review by the time of the survey. Both instances demonstrate that the facility did not ensure that the residents' guardians were fully informed and had provided documented consent prior to the administration of psychotropic medications.
Plan Of Correction
F552 – Right to be Informed/Make Treatment Decisions Element #1: For Residents #33 and #41, physician orders for psychotropic medications were reviewed, and informed consent forms were obtained as necessary. The guardians were notified and documentation updated in the medical record. Element #2: A comprehensive audit of all residents on psychotropic medications was completed by the Director of Nursing to verify that current signed informed consents are present in the medical record. Any missing documentation will be obtained and filed. Element #3: The Administrator and Director of Nursing implemented a new Psychotropic Medication Informed Consent to ensure residents/responsible parties are made aware of the medication, benefits, potential adverse reactions, and alternate interventions. Licensed Nurses were re-educated on this document and the requirement for a signed consent prior to the distribution of the medication. Element #4: The Director of Nursing or designee will audit all new psychotropic medication orders weekly for 12 weeks to verify compliance with informed consent requirements. Results of the audits will be submitted to the QAPI.
Failure to Ensure Accurate Code Status in EMR Following DNR Documentation
Penalty
Summary
The facility failed to ensure the accuracy of code status information for a resident who was reviewed for advance directives. The resident, who had a history of hemiplegia, hemiparesis following a stroke, vascular dementia, and chronic kidney disease, was admitted with the ability to make their own medical decisions. The medical record initially reflected a physician's order indicating full code status. However, the resident and two witnesses later signed a Do Not Resuscitate (DNR) form, which was subsequently signed by the physician and scanned into the electronic medical record (EMR). Despite the completion and physician signature of the DNR form, the code status displayed in the EMR banner remained as full code, while the DNR form in the Miscellaneous section indicated DNR status. Interviews with nursing staff revealed reliance on the EMR banner for code status during emergencies, with one RN noting the discrepancy between the banner and the DNR documentation. The social worker responsible for advance directives acknowledged that the code status was not updated in the EMR banner after the physician signed the DNR form, possibly due to a lack of communication regarding the need to change the code status.
Plan Of Correction
F578 - Right to Refuse/Discontinue Treatment and Advance Directives Element #1: Resident #36's EMR was updated to reflect their current wishes for Advanced Directives. A reconciliation process was conducted between the documented code status and the banner in the EMR. Element #2: The Social Worker audited all residents to confirm accuracy in code status documentation. Any discrepancies were corrected and documented. Element #3: The policy Residents' Rights Regarding Treatment and Advanced Directives was reviewed and updated as necessary by the Administrator. Social Services and Licensed Nurses were educated on the policy and procedure. Element #4: The Social Worker or designee will review new physician orders weekly, Monday through Friday, for 12 weeks to ensure documentation is correctly reflected in all relevant systems. Any discrepancies will be reported in the audits and corrected immediately. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Safeguard and Track Resident's Personal Belongings
Penalty
Summary
A resident with legal blindness, muscle weakness, and cognitive intactness was admitted to the facility and relied on personal items, including a DVD set gifted by his daughter, to support his daily living and comfort. The resident reported that the DVD set was stolen the same day it was brought into the facility, and both he and his family reported the missing item to facility staff by submitting a concern form. The DVD set was important to the resident as it allowed him to watch his favorite show using headphones, which was necessary due to his roommate's loud television use. Despite the family submitting a concern form to the receptionist, and the receptionist recalling turning the form in to the administrator, there was no documentation or follow-up regarding the missing DVD set. The facility was unable to produce any grievance or concern forms related to the missing item, and the assistant director of nursing indicated that paperwork that should have been in the previous administrator's office could not be located. As a result, the resident's personal belongings were not safeguarded or made available for his use, and the facility failed to ensure a safe, comfortable, and homelike environment as required.
Plan Of Correction
F584 - Safe/Clean/Comfortable/Homelike Environment Element #1: R38's missing DVD set was replaced and an inventory checklist was reissued to the resident and updated. Element #2: The Social Service Director conducted an audit of all resident grievances and personal belongings reports to ensure appropriate follow-up. Any open items were addressed and resolved. Element #3: The policy on Resident and Family Grievances was reviewed by the Administrator and updated as necessary. Community staff were re-educated on the grievance process, along with resident inventories. Element #4: The Administrator or designee will audit the concern log weekly for 12 weeks to confirm timely follow-up on any resident property issues. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Limit PRN Psychotropic Medication Duration and Document Physician Rationale
Penalty
Summary
The facility failed to limit the duration of a PRN psychotropic medication to 14 days and did not ensure that the physician documented a rationale to extend the use of the medication for one resident. The medical record review showed that a resident with major depressive disorder and early-onset Alzheimer's, who had severe cognitive impairment, had an active physician order for Lorazepam (Ativan) 0.5 mg to be given every 4 hours as needed for anxiety. This order was initiated and remained active beyond the 14-day limit without evidence of discontinuation or physician documentation justifying continued use. The Director of Nursing confirmed that the order should have been discontinued after 14 days and reevaluated for continued use.
Plan Of Correction
F605 – Right to be Free from Chemical Restraints Element #1: The PRN order for Lorazepam for Resident #33 was discontinued after review and discussion with the physician. Element #2: The Director of Nursing initiated a full audit of all psychotropic medications with PRN orders on to ensure compliance with PRN orders. Any noncompliant orders were corrected immediately. Element #3: The Psychotropic Medication Policy was reviewed by the Administrator and revised as necessary. Licensed Nurses and Providers were re-educated on the regulation F605 and
Failure to Provide Required Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to both the resident and their representative, as well as to the ombudsman, for one resident. The resident, who had diagnoses including diabetes, quadriplegia, anxiety, and atrial fibrillation, was admitted to the facility and later experienced an unplanned discharge to the hospital, with no return anticipated. Review of the medical record and health status notes confirmed the transfer to the hospital, but there was no documentation that the required written notice was given. During interviews, both the Director of Nursing and Assistant Director of Nursing stated they were unaware of the requirement to send such notices and therefore did not provide or document them.
Plan Of Correction
F628 – Discharge Process Element #1: R#67 no longer resides in the community. Element #2: A full audit of discharges within the past 90 days was initiated by the Social Worker to ensure notification letters and documentation were completed. Any missing notifications were sent. Element #3: The Administrator reviewed the regulation F628 and updated the Discharge Checklist to include evidence of the mailed or emailed communication. Licensed Nurses and Social Work were educated on the guidelines for F628. Element #4: The Social Worker and/or designee will audit all discharges weekly for 12 weeks to confirm notice was provided to both the resident/representative and monthly to the Ombudsman. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Accurately Complete Comprehensive Assessment for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to accurately complete a comprehensive assessment for one resident upon admission and during subsequent assessments. The resident, who had diagnoses including muscle weakness, contractures in both legs, dementia, and pressure-induced deep tissue damage of the left heel, was admitted and later readmitted to the facility. Upon observation, the resident was found wearing pressure-relieving boots, with one boot nearly detached. Family interview confirmed the resident was unable to move his legs due to muscle atrophy and contractures, and had developed a sore on his heel. Medical records and wound care notes documented an unstageable pressure ulcer on the left heel, with specific measurements and wound characteristics provided by outside wound care services. Despite this documentation, the facility's Quarterly Minimum Data Set (MDS) assessment did not accurately reflect the presence of the unstageable pressure ulcer, as the relevant section was marked as having no such ulcer. This discrepancy between the wound documentation and the MDS assessment demonstrates the facility's failure to complete a comprehensive and accurate assessment of the resident's condition as required.
Plan Of Correction
F636 – Comprehensive Assessments & Timing Element #1: R20's comprehensive assessment and care plan were updated and completed. R20 was assessed by the Director of Nursing and/or designee to ensure no lasting effects related to the inaccurate assessment. Element #2: An audit of all residents admitted in the past 6 months was conducted by the MDS Coordinator and/or designee to ensure that comprehensive assessments were completed on time and accurately. Element #3: The Administrator reviewed the regulation F636, and education was provided to Licensed Nurses and Department Managers on the regulation and guidelines. Element #4: The MDS Coordinator and/or designee will review the assessment tracker weekly for 12 weeks to verify timely completion and accuracy of comprehensive assessments. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Complete SCSA MDS After Development of Pressure Ulcers
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for a resident who experienced a notable decline in health status. The resident, who had a history of vascular dementia, wheelchair dependence, and diabetes, was observed multiple times without a seating cushion in their wheelchair and was later found lying in bed. Medical records indicated the development of two facility-acquired stage II pressure ulcers in the left intergluteal region and posterior scrotum, which were still present and unhealed upon assessment by a nurse practitioner. Despite the emergence of these new stage II pressure ulcers, which meets the criteria for a significant change in status, the MDS Registered Nurse reported that a SCSA MDS was not conducted and was unaware of the pressure ulcers. The nurse also stated that SCSA MDS assessments were typically done for hospice admissions or discharges, not for pressure ulcers, and believed it was at the facility's discretion to conduct them for other changes. This lack of assessment resulted in the absence of a care plan revision to address the resident's new pressure ulcers.
Plan Of Correction
F637 - Comprehensive Assessment After Significant Change Element #1: The MDS Coordinator completed the significant change assessment for R11. The resident's care plan was reviewed and revised based on updated assessment data. R11 was assessed by the Director of Nursing and/or designee to ensure no lasting effects related to the incomplete significant change assessment. Element #2: The MDS Coordinator and/or designee initiated a review of current residents with recent hospitalizations, new diagnoses, or care plan changes in the last 30 days to identify if additional significant change assessments were warranted. Assessments will be initiated based on results of the 100% audit. Element #3: The Administrator reviewed the regulation F637. Licensed Nurses and Department Managers were provided education on significant change assessments, and the guidelines for F637. Element #4: The MDS Coordinator and/or designee will review weekly nursing reports and change-of-condition documentation to identify any missed significant change triggers for 12 weeks. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Inaccurate MDS Assessments and Incomplete Documentation
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for three residents, resulting in deficiencies in the documentation of active diagnoses, cognitive patterns, mood, and fall history. For one resident, the medical record showed a diagnosis of severe depression and a prescription for Lexapro, but the MDS assessment did not reflect depression as an active diagnosis. The MDS Coordinator confirmed that the diagnosis should have been documented as present during the assessment period, but it was incorrectly marked as absent. Two other residents had their Quarterly MDS assessments completed without proper evaluation of cognition and mood. The relevant sections of the MDS were left unassessed, with responses marked as dashes or 'Not assessed.' Staff interviews revealed that one resident exhibited behaviors such as refusal of care, screaming, and yelling, but these were not captured in the MDS due to the absence of a social worker during the assessment period. The MDS Registered Nurse reported that interviews required for these sections could not be conducted after the assessment reference date, resulting in incomplete documentation. Additionally, the review of one resident's MDS history showed discrepancies in the reporting of falls. Incident reports indicated that the resident had experienced multiple falls, but these were not coded on the corresponding MDS assessments. The MDS assessments failed to accurately reflect the resident's fall history, despite documentation of the incidents in the facility's records.
Plan Of Correction
F641 – Accuracy of Assessments Element #1: The MDS Coordinator reviewed and corrected inaccuracies in the submitted MDS for R9, R11, and R40. Corrections were submitted to CMS as needed. R9, 11, and 40 were assessed by the Director of Nursing and/or designee to ensure no lasting effects related to inaccurate assessment. Element #2: A 100% audit of MDS assessments completed in the last 30 days was initiated by the MDS Coordinator and designee team to identify and correct any additional inaccuracies. Element #3: The Administrator reviewed the policy on Conducting an Accurate Resident Assessment and revised as necessary. Education was provided to the Licensed Nurses and Department Managers on the policy and procedure for completion of accurate assessments. Element #4: The MDS Coordinator and/or designee will randomly review 3 assessments per week for 12 weeks for accuracy and documentation verification. All discrepancies will be logged and assessments modified to ensure accuracy. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Develop and Implement Comprehensive Care Plan for Pressure Ulcer Management
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address all of a resident's needs, specifically regarding the management and prevention of pressure ulcers. The resident, who was dependent on a wheelchair and had diagnoses including vascular dementia and diabetes, was observed multiple times without a seating cushion in the wheelchair and without linens on the bed. The medical record indicated the development of two facility-acquired stage II pressure ulcers in the intergluteal region and posterior scrotum. Recommendations from a nurse practitioner for a low air loss mattress and a pressure-relieving wheelchair cushion were documented, but these interventions were not observed in use during multiple observations. The care plan for the resident did not reflect the presence of pressure ulcers or include interventions for pressure relief, despite the documented wounds and recommendations. The MDS assessment did not include cognition and mood assessments, and the MDS nurse was unaware of the pressure ulcers, acknowledging that their development should have triggered a significant change assessment and a corresponding care plan. Existing care plans referenced impaired skin integrity but did not specify the pressure ulcers or detail appropriate interventions for pressure relief.
Plan Of Correction
F656 – Develop/Implement Comprehensive Care Plan Element #1: The facility updated the care plan for R11 to reflect current clinical status and interventions. Element #2: A review was initiated by the Director of Nursing and/or designee of all new admissions in the past 30 days to ensure comprehensive care plans were developed and implemented within the required timeframe, and are an accurate reflection of the resident's status. Element #3: The Administrator reviewed the policy on Comprehensive Care Plans and revised as necessary. Education on the policy was provided to Licensed Nurses and Department Managers to ensure Care Plans are up to date and accurate to reflect the resident's status. Element #4: The Director of Nursing and/or designee will review 5 residents weekly for 12 weeks to confirm accuracy and timeliness of care plans and interventions. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Missed Quarterly Care Conference for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to conduct a required quarterly care conference for one resident who was admitted with major depressive disorder and early-onset Alzheimer's disease. The resident's medical record indicated severe cognitive impairment, as evidenced by a score of 0 out of 15 on the Brief Interview for Mental Status (BIMS). Documentation showed that the last care conference was held in December, and the next was due in March but was not conducted. Family reported inconsistencies with care conferences, and staff confirmed that the conference was missed due to the recent loss of the facility's social worker, resulting in delays in scheduling and documentation.
Plan Of Correction
F657 – Care Plan Timing and Revision Element #1: Social worker held a quarterly care conference for R33 on 05.12.2025. Element #2: The Social Service Director conducted a 100% audit of residents to ensure care conferences are held timely and per policy. Element #3: The Administrator reviewed the regulation F657. Licensed Nurses and Department Managers were provided education on the regulation and its guidelines. Element #4: The Social Service Director will conduct weekly audits of 5 residents to ensure their care conferences have been scheduled and held per regulatory guidelines. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Provide Consistent and Meaningful Activities for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide consistent and meaningful activities, ensure adequate staffing and staff engagement, and maintain accountability for the implementation of scheduled activities for a resident with severe cognitive impairment and major depressive disorder. Observations revealed that the resident spent significant time sitting in a chair without engagement, despite scheduled activities being posted. Activity staff were observed not interacting with residents, instead using personal phones or completing crafts alone. Scheduled activities, such as a balloon toss, did not occur as planned, as confirmed by both nursing and activity staff. Interviews with family members and staff indicated concerns about the lack of life enrichment and engagement for the resident, with staff reporting increased responsibility to provide interaction due to inconsistent activity staff presence. The Activities Director acknowledged challenges with staffing, training, and the need for more structured, sensory-based activities, but also noted that staff should not be on their phones and are expected to engage with residents during scheduled activities. These findings demonstrate a failure to implement and maintain a consistent and meaningful activities program for residents, particularly those with cognitive impairments.
Plan Of Correction
F679 – Activities Meet Needs/Interests of Each Resident Element #1: The Activity Director met with Resident #33 to assess personal preferences, interests, and participation barriers. The resident’s care plan was updated to include individualized activity interventions aligned with their preferences. The resident was also reintroduced to one-on-one and small group programming, and staff were assigned to ensure engagement during scheduled activities. Element #2: The Activity Director conducted an audit of all residents’ activity care plans and participation records to identify residents who have had limited engagement or inconsistencies in scheduled activities. Residents with low participation or dissatisfaction with current offerings were flagged for follow-up by the Activities Department. Element #3: The Administrator reviewed the policy on Activities and revised as necessary. Community staff were re-educated on the policy for Activities to include the importance of person-centered programming and timely execution of the daily activity schedule. Element #4: The Activity Director and/or designee will conduct weekly audits of scheduled activity implementation, participation logs, and resident feedback for 12 weeks. At least 5 residents will be randomly selected weekly to verify engagement and satisfaction. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Provide Double Protein Portions as Ordered
Penalty
Summary
The facility failed to follow a physician's order to provide double protein portions for a resident with diagnoses including heart failure and both acute and chronic respiratory failure with hypoxia. Despite a physician's order dated 2/21/25 and revised on 4/21/25 for double protein portions, observations on 05/05/25 and 05/07/25 showed that the resident received meal portions consistent with other residents, not the prescribed double protein. The resident's weight records indicated a decline from 222.0 pounds to 210.2 pounds over several months. The registered dietitian confirmed that the intervention for double protein portions was implemented in response to observed weight loss and that the expectation was for the order to be followed, but it was not adhered to during the observed meals. These findings were based on direct observation, record review, and staff interview, demonstrating a failure to provide adequate nutrition as ordered for the resident.
Plan Of Correction
F692 – Nutrition/Hydration Status Maintenance Element #1: R20's diet orders and care plan were reviewed and modified as needed. R20 was assessed by the Director of Nursing and/or designee to ensure no lasting effects from missing double portions. Element #2: The RD and/or designee conducted an audit of community residents with orders for double protein portions to ensure care plans and interventions are accurate per resident current status. Element #3: The Administrator reviewed the policy on Nutrition and Hydration and revised as necessary. Community staff were provided education on following orders, and verification of information on tray tickets to ensure residents receive meals as ordered. Element #4: The RD and/or designee will review 10 residents weekly for 12 weeks to ensure meals are delivered in accordance with the orders and preferences indicated on their tray ticket. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with three medication errors observed out of 25 opportunities, resulting in a 12% error rate. During medication administration, a registered nurse gave a resident an iron pill from a bottle that lacked a manufacturer's expiration date. The nurse was unaware of the significance of the handwritten date on the bottle and administered the medication without verifying its expiration, then returned the bottle to the medication cart for future use instead of disposing of it. In another instance, an LPN administered Senna Plus 8.6/50 mg to a resident, despite the physician's order not specifying a dose for Senna. The LPN stated she gave the combination medication because the order did not indicate a specific dose. Additionally, another LPN was observed preparing to administer Losartin 50 mg to a resident without initially checking for blood pressure parameters, only discovering the parameters after reviewing the physician's orders. These actions contributed to the facility's elevated medication error rate.
Plan Of Correction
F759 – Free of Medication Error Rates = 5% Element #1: On 5/27/2025, the licensed nurse involved in the medication error received immediate re-education on proper medication administration protocols and documentation. Element #2: A full-house audit was conducted to ensure expired medications are disposed of appropriately, and that medication orders are complete to include dosage and parameters if necessary. Element #3: The Administrator reviewed the policy on Medication Administration and revised as necessary. Licensed Nurses were re-educated on the policy and procedure for medication administration. Element #4: The Director of Nursing and/or designee will perform 5 random medication administration observations weekly for 12 weeks. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Change Oxygen Tubing Weekly as Required
Penalty
Summary
The facility failed to ensure that oxygen tubing was changed every seven days for one resident, as required by facility policy. During observations, a resident was noted to have oxygen tubing in use that was labeled with a date indicating it had not been changed for over two weeks. The Infection Control Preventionist, who is also a Registered Nurse, stated that she did not monitor or track the use of oxygen tubing through the infection control program and did not perform audits to ensure compliance with the seven-day change policy. The Director of Nursing confirmed that the expectation was for the Infection Control Preventionist to conduct monthly audits and random checks to verify that oxygen tubing was being changed and dated as per policy. Review of the facility's policy confirmed that oxygen tubing should be changed weekly and as needed if soiled or contaminated.
Plan Of Correction
F880 – Infection Prevention & Control Element #1: R#61 was assessed by the Director of Nursing or designee to ensure no lasting effects related to outdated oxygen tubing. Element #2: A facility-wide audit will be completed by the Director of Nursing and/or designee to ensure compliance with changes to oxygen tubing. Element #3: The Administrator reviewed the policy on Oxygen Administration and revised as necessary. Clinical staff were provided re-education related to infection control and oxygen administration. Element #4: The Infection Preventionist and/or designee will conduct rounds 3 times per week for 12 weeks to monitor infection control practices and ensure oxygen tubing is changed per policy. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Lack of Documentation for Pneumococcal Vaccine Education
Penalty
Summary
The facility failed to document that education regarding the benefits and potential side effects of the pneumococcal immunization was provided to two residents. One resident, who had diagnoses including COPD and diabetes and was assessed as cognitively intact, initially declined the pneumonia vaccine but later consented and received it. However, there was no documentation in the medical record indicating that education about the vaccine's benefits and risks was provided prior to administration. The Director of Nursing and Assistant Director of Nursing/Infection Preventionist confirmed that the CDC Vaccine Information Statement should have been given, but no documentation of this education was available. Similarly, another resident with COPD and diabetes, also assessed as cognitively intact, declined the pneumonia vaccine initially but later received it. The medical record noted the administration of the vaccine and that the resident tolerated it well, but did not reflect any education provided regarding the vaccine's benefits or potential side effects. During an interview, the resident confirmed consent for the vaccine but reported not receiving any education on its risks or benefits. The DON and ADON/IP acknowledged that education should have been provided and documented, but no such documentation was found.
Plan Of Correction
F883 – Influenza and Pneumococcal Immunizations Element #1: Resident #2 and #22 were assessed to ensure no lasting effects related to insufficient education regarding vaccine administration. Element #2: The Director of Nursing and/or designee conducted a full-house audit to ensure residents receiving immunizations have been provided the appropriate education. Element #3: The Administrator reviewed the policy General Immunization and revised as necessary. Licensed Nurses were provided education on the policy and the need for resident/responsible party education regarding vaccinations. Element #4: The Director of Nursing and/or designee will conduct weekly audits of immunization status for 12 weeks to ensure appropriate education. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Incomplete Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the daily nurse staffing postings were fully compliant with regulatory requirements. On multiple consecutive days, the postings displayed in the main lobby included the date (month and day) and the total hours worked for RNs, LPNs, and CNAs for both day and night shifts. However, the postings did not include the current year or the specific shift times. During an interview, the Director of Nursing stated that the Scheduler was responsible for preparing the daily staffing postings and may have been using an outdated form.
Plan Of Correction
F732 – Posted Nurse Staffing Information Element #1: On 5/09/2025, the Staffing Coordinator updated the posted nurse staffing forms to include the full date, including the year, and added the actual hours worked per category (RN, LPN, CNA) for both shifts. Element #2: An audit of staffing postings for the prior 30 days was conducted by Human Resources to ensure historical compliance and address any discrepancies. Element #3: The Administrator reviewed the policy for Nurse Staffing Posting Information and revised as necessary. Community staff were provided education regarding posted nursing staffing data and the requirements. Element #4: The Scheduler and/or designee will audit staffing postings daily, Monday through Friday, for 12 weeks to verify they are accurate, complete, and posted timely. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Administer COVID-19 Vaccine per Consent
Penalty
Summary
A resident with Alzheimer's Disease and diabetes, who was assessed as having severe cognitive impairment, was admitted to the facility and had their spouse designated as Durable Power of Attorney (DPOA) for Healthcare. The DPOA provided verbal consent for the resident to receive a COVID-19 vaccine, as documented on the COVID-19 Vaccine Consent Form. Despite this consent, the resident did not receive the updated COVID-19 vaccine. Review of the immunization history confirmed that the most recent COVID-19 vaccine was administered several months prior to the consent. During interviews, the Director of Nursing (DON) and Assistant Director of Nursing/Infection Preventionist (ADON/IP) were unable to provide documentation or an explanation for why the vaccine was not administered as consented.
Plan Of Correction
F887 – COVID-19 Immunization Element #1: Resident #33 was assessed by the Director of Nursing and/or designee to ensure no lasting effects related to not receiving Covid-19 immunization. Element #2: The Director of Nursing and/or designee reviewed the last 60 days of resident documentation to ensure residents were offered and provided immunization based on consent. Element #3: The Administrator reviewed the policy on General Immunization and revised and necessary. Licensed Nurses were provided re-education on the vaccine policy and procedure to ensure residents consenting to vaccines receive them timely. Element #4: The Director of Nursing and/or designee will audit new admissions weekly to ensure any resident consenting to a vaccination receives it in a timely manner. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Psychotropic Medications Administered Without Signed Consent
Penalty
Summary
Two residents with severe cognitive impairment and dementia were administered psychotropic medications without proper consent documentation. One resident, diagnosed with major depressive disorder and early-onset Alzheimer's disease, was prescribed Lorazepam for anxiety, and the family guardian was not informed of the new medication order. Although a request for consent was initiated, a signed consent was not obtained or available for review. Another resident with dementia received Zyprexa, an antipsychotic, without a signed consent present in the medical record at the time of survey exit. These findings reflect that psychotropic medications were administered to residents without the required signed consents, as confirmed by medical record review and family interview, and the necessary documentation was not available during the survey.
Plan Of Correction
Committee monthly for review. The QAPI Committee will be responsible for changes to the auditing process. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025
Failure to Conduct and Document Required Emergency Preparedness Exercises
Penalty
Summary
The facility failed to conduct the required exercises to test its emergency plan at least annually, as mandated by federal regulations. Specifically, record review on 05/07/2025 revealed that the facility did not perform a second full-scale exercise, tabletop exercise, or individual facility-based exercise that would qualify as a test of the emergency plan within the past year. No documentation was provided to demonstrate that any such exercise had taken place during the required timeframe. This deficiency was confirmed during an interview with the Facility Maintenance Director at the time of record review. The absence of documentation and lack of evidence for the required emergency preparedness exercises indicated non-compliance with the established emergency preparedness testing requirements. The report does not mention any specific patients, residents, or staff members directly affected at the time of the deficiency. The focus of the deficiency is on the facility's failure to meet regulatory requirements for emergency preparedness exercises and documentation, which could potentially impact all occupants in the event of an emergency.
Plan Of Correction
E039 1. The Administrator will conduct a review of the Emergency Preparedness plan and policies. The Maintenance Director will participate in/ conduct a community or facility-based exercise to test the Emergency Preparedness system. 2. The Administrator will review regulation E039 and provide education to the Maintenance team on the requirements. 3. The Maintenance Director and/or designee will utilize the preventative maintenance system to ensure exercises are scheduled annually. Results of the annual exercise will be brought to the Quality Assurance Performance Improvement meetings for review. The Committee will determine whether modifications to the plan are necessary. 4. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.
Ceiling Tile Gaps Compromise Flame Spread Rating Requirements
Penalty
Summary
The facility failed to ensure that interior wall and ceiling finishes, specifically ceiling tiles, maintained the required flame spread rating of Class A or B, as mandated by regulations. During observations, surveyors identified 1-inch gaps between the base of exit signs and the ceiling tiles at the entrances of both the South Hall and North Hall smoke compartment doors, located near the Administrator's office and the Director of Nursing office, respectively. These deficiencies were confirmed by the Facility Maintenance Director at the time of observation. No information regarding residents' medical history or condition at the time of the deficiency is provided in the report.
Plan Of Correction
K3311. The Maintenance Director and/or designee will repair the gaps between the ceiling tiles and exit signage at the entrance of South Hall and North Hall. The Administrator will review regulation K331 and provide education to the Maintenance team on the requirements. The Maintenance Director and/or designee will conduct weekly rounds of the community to ensure no gaps in the ceiling tiles. Results of the audits will be brought to the Quality Assurance Performance Improvement meeting monthly for review. The Committee will be responsible for any changes to the auditing process. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.
Improper Installation and Obstruction of Fire Alarm System Components
Penalty
Summary
The facility failed to ensure that the fire alarm system was installed and maintained in accordance with NFPA 70 and NFPA 72 standards. During an observation, it was found that the smoke detector head at the North Smoke Doors exit into the administration hall was not properly mounted to the ceiling. Additionally, another smoke detector head located in the North Mechanical closet was discovered with a plastic bag taped over it. These deficiencies were confirmed through interviews with the Facility Maintenance Director at the time of the observations. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K3411. The Maintenance Director and/or designee will repair the smoke detector heads at the North smoke doors and North mechanical closet. The Administrator will review regulation K341 and provide education to the Maintenance team on the requirements. The Maintenance Director and/or designee will conduct a weekly community audit of smoke detectors to ensure appropriate function. Results of the audits will be brought to the Quality Assurance Performance Improvement meeting monthly for review. The Committee will be responsible for any changes to the auditing process. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.
Failure to Maintain Smoke-Resistant Corridor Doors
Penalty
Summary
Surveyors observed that the facility failed to ensure that doors protecting corridor openings were capable of resisting the passage of smoke as required by NFPA 19.3.6.3. Specifically, on three separate occasions, it was found that the North Dining Room door across from resident room 125 was missing a latch and would not properly latch when tested, and the North Dining Room door across from resident room 107 also would not latch. Additionally, Resident Room 125 was found to have a 2-inch gap between the door and the floor, exceeding the maximum allowable clearance. These deficiencies were confirmed through direct observation and interview with the Facility Maintenance Director at the time of the survey. The report does not mention any specific residents' medical history or conditions at the time of the deficiency, nor does it indicate any immediate harm, but it documents the failure of the facility to maintain corridor doors in accordance with fire safety regulations.
Plan Of Correction
K363 1. The Maintenance Director and/or designee will repair the North Dining Room doors to ensure a positive latch, along with the gap in resident room 125 door. 2. The Administrator will review regulation K363 and provide education to the Maintenance team on the requirements. 3. The Maintenance Director and/or designee will conduct weekly rounds of doors protecting corridor openings to ensure no gaps and that doors close to a positive latch. Results of the audits will be brought to the Quality Assurance Performance Improvement meeting monthly for review. The Committee will be responsible for any changes to the auditing process. 4. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.
Failure to Maintain and Document Required Generator Testing and Maintenance
Penalty
Summary
The facility failed to maintain compliance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 requirements for essential electrical systems, specifically regarding the generator and its associated equipment. During a record review, surveyors found that the facility did not provide documentation of a current monthly generator load test, with the last available record dating back to August 2024. Additionally, there was no documentation available for a current annual load bank test, annual service of the generator, or annual fuel analysis test for the generator fuel. These deficiencies were identified during a survey on 05/07/2025, and no current records for the required maintenance and testing were provided by the time the survey concluded. The lack of these records indicates that the facility did not ensure the generator and its components were properly maintained and tested as required, which could affect all occupants in the event of a power failure. No specific residents or patient conditions were mentioned in the report.
Plan Of Correction
The Maintenance Director and/or designee will schedule monthly generator load testing, annual load bank, service, and fuel analysis testing to be completed by the compliance date. The Administrator will review regulation K918 and provide education to the Maintenance team on the requirements. The Maintenance Director and/or designee will ensure the Preventative Maintenance system has all required generator testing scheduled to ensure regulatory compliance based upon education for tag 0918. Results of the required testing will be brought to the Quality Assurance Performance Improvement meetings for review. The Committee will determine whether modifications to the plan are necessary. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.
Failure to Submit Construction Plans for Fire Safety Review
Penalty
Summary
The facility failed to submit required plans and specifications to the Bureau of Fire Services for a construction project involving newly built walls between the Activities Office and Dietary Office. During an observation, a newly constructed diagonal wall in the Activities Office and a straight wall in the Dietary Office were identified, with a void area approximately three feet wide where suppression coverage was unknown. No documentation or plans for this construction were provided to the surveyor upon request or by the end of the survey. This deficiency was confirmed through interviews with the Facility Maintenance Director and Facility Maintenance staff at the time of observation.
Plan Of Correction
K1001. The Maintenance Director and/or designee will remove the constructed wall between the Activity Office and Dietary. The Administrator will review regulation K100 and provide education to the Maintenance team on the requirements. The Maintenance Director and/or designee will conduct weekly rounds of the community spaces to ensure no lack of suppression coverage, and no new construction is completed without prior approval. Results of the audits will be brought to the Quality Assurance Performance Improvement meeting monthly for review. The Committee will be responsible for any changes to the auditing process. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.
Failure to Maintain and Test Sprinkler System per NFPA 25
Penalty
Summary
The facility failed to comply with NFPA 25 requirements for the inspection, testing, and maintenance of its automatic sprinkler system. Specifically, records showed that the 2nd, 3rd, and 4th quarter sprinkler flow tests were not conducted or documented, as no test results were available at the time of the survey. Additionally, an observation in the therapy room revealed a sprinkler head dated 1967, indicating it had not been replaced or updated in over 50 years. These deficiencies were confirmed through record review and interview with the Facility Maintenance Director.
Plan Of Correction
K353 1. The Maintenance Director and/or designee will conduct a sprinkler flow test and replace the sprinkler head in the Therapy room. 2. The Administrator will review regulation K353 and provide education to the Maintenance team on the requirements. 3. The Maintenance Director and/or designee will ensure sprinkler system maintenance is scheduled for the remainder of 2025. The Maintenance Director and/or designee will ensure the Preventative Maintenance system flags for sprinkler system maintenance to ensure compliance. Results of sprinkler system testing will be brought to the Quality Assurance Performance Improvement meeting monthly for review. 4. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.
Smoke Barrier Door Failed to Close Properly
Penalty
Summary
Smoke compartment door #9 did not close to a smoke-tight fit when tested during an observation. The door sweep at the bottom of the door was catching on the floor, which prevented the door from releasing properly and closing as required. The door would not close without staff assistance to move it from the magnetic release. This issue was confirmed by the Facility Maintenance Director at the time of observation. The deficiency could affect 30 occupants in the event of a fire emergency, as the door did not meet the Life Safety Code (LSC) requirements for smoke barrier doors.
Plan Of Correction
K374 1. The Maintenance Director and/or designee will repair the smoke compartment door #9 to ensure it closes properly to prevent the passage of smoke. 2. The Administrator will review regulation K374 and provide education to the Maintenance team on the requirements. 3. The Maintenance Director/designee will conduct a weekly round of smoke compartment doors to ensure they close properly. The Maintenance Director will ensure rounding is logged into the Preventative Maintenance program to ensure continued assessment of function. Results of the audits will be brought to the Quality Assurance Performance Improvement meeting monthly for review. The Committee will be responsible for any changes to the auditing process. 4. The Administrator is responsible to attain and maintain compliance. Completion date for compliance will be 06.20.25.
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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