Pomeroy Living Rochester Skilled Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochester Hills, Michigan.
- Location
- 3500 West South Blvd, Rochester Hills, Michigan 48309
- CMS Provider Number
- 235477
- Inspections on file
- 24
- Latest survey
- August 28, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pomeroy Living Rochester Skilled Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that appropriate care was not provided for residents regarding continence management, catheter care, and UTI prevention. The report notes lapses in these areas but does not specify the actions or omissions or provide details about the residents involved.
A resident with dementia and a change in condition did not have ordered CBC and CMP labs completed, and abnormal urinalysis and culture results indicating E. Coli were not promptly reported to the practitioner or acted upon. There were significant delays in both laboratory processing and facility notification, and the facility lacked a policy for ordering and reporting lab results.
The facility failed to maintain sanitary conditions in the kitchen, with observations of soiled equipment, mold-like substances, and pest presence. Additionally, staff did not sanitize thermometer probes when measuring food temperatures, potentially risking foodborne illness among residents.
The facility's assessment was not reviewed and revised per regulatory requirements, affecting 117 residents. The assessment lacked involvement from the Medical Director, direct care staff, and input from residents and families. The Administrator acknowledged the oversight and scheduling conflicts prevented attending resident council meetings.
The facility failed to implement and maintain enhanced barrier precautions (EBP) for three residents, potentially affecting all 117 residents. The infection prevention program lacked consistent documentation, and staff did not follow proper hand hygiene or EBP protocols. Residents with catheters and wounds lacked necessary signage and PPE, and linen carts were improperly maintained with non-linen items stored among clean linens.
A facility failed to properly store and label medications, as observed during a survey. A resident had a tube of ointment on their bedside table without documentation for self-administration. Multiple medication carts had issues such as unlocked drawers, unlabeled insulin pens, and improper storage of food items with medications. Loose pills were also found in a medication drawer without identification.
The facility failed to implement an effective antibiotic stewardship program, leading to inconsistent antibiotic use for three residents. One resident lacked documentation for antibiotic necessity and had an incomplete treatment for clostridium difficile. Another resident was prescribed an antibiotic without a start date, missing the first dose. A third resident experienced a delay in starting their antibiotic treatment. The facility's infection control preventionist acknowledged these lapses.
A facility failed to provide water within reach for a resident, despite clear instructions and care plan interventions. Observations showed the resident's water was consistently placed out of reach, and the issue was acknowledged by the Assistant DON. A policy on accommodation of needs was requested but not provided.
A resident's request to change their code status to DNR was not honored due to the facility's policy requiring a physician's signature, despite the resident's clear wishes and signing of a DNR form. The facility continued to list the resident as a full code, and staff confirmed that CPR would be initiated if necessary, highlighting a delay in updating the resident's medical records.
The facility failed to follow professional standards in medication administration for two residents. One resident's blood sugar level was not documented as required, and another resident's blood pressure medications were administered late. The responsible nurses admitted to these oversights, and the ADON confirmed the facility's protocols were not followed.
A resident requiring assistance for all ADLs, including oral care, did not receive necessary help with brushing their teeth. The resident's daughter expressed concerns, and the resident confirmed the lack of assistance. The CNA assumed oral care was completed by the previous shift, which was not the case. The ADON acknowledged the oversight, but no further documentation was provided.
The facility failed to timely implement treatments for a fungal rash and edema for two residents and did not obtain a physician-ordered blood sugar level for another resident. A resident's prescribed ointment for a fungal rash was not applied upon admission, worsening the condition. Another resident did not receive prescribed ACE wraps for edema due to a shortage, leading to extended dialysis. Additionally, a resident's blood sugar was not checked as scheduled, affecting insulin administration.
A resident experienced a 22.94% weight loss over a period, and the facility failed to conduct timely nutritional assessments or interventions. Despite the resident's medical history of moderate protein-calorie malnutrition and chronic kidney disease, no dietary assessments were conducted during the critical period of weight loss. The facility's policy required monitoring of significant weight changes, which was not adhered to, leading to the deficiency.
A facility experienced a 10.34% medication error rate during a survey. Errors included a nurse withholding a blood pressure medication without proper parameters and administering the wrong allergy medication. Another nurse gave a nighttime cholesterol medication in the morning and misrepresented it as a vitamin to a resident. These issues were acknowledged by the facility's ADON and Administrator.
The facility failed to serve meals at desirable temperatures, leading to resident dissatisfaction. Multiple complaints were made about cold food, particularly breakfast. Observations confirmed that some food items were served cold, and the Registered Dietician acknowledged challenges in maintaining food temperature due to staffing issues. The facility's administrator was informed of these concerns, but the policy on food palatability was not provided to the survey team.
The facility failed to administer medications and treatments as prescribed for three residents, leading to deficiencies in care. One resident did not receive a STAT x-ray or Zofran before leaving AMA. Another experienced delays in medication and skin treatment applications. A third resident did not receive their weekly pain patch as ordered. The DON acknowledged these failures, highlighting issues with adherence to physician orders and timely administration.
The facility failed to provide oxygen services per physician orders for two residents, leading to significant health issues. One resident was sent to a medical appointment with an empty oxygen tank, resulting in hospitalization due to low oxygen saturation. Another resident experienced breathing difficulties due to conflicting oxygen orders, with no clarification on which order to follow. The facility's lack of communication and verification of oxygen levels contributed to these deficiencies.
A resident with Parkinson's Disease and severely impaired cognition, under hospice care, experienced inadequate pressure ulcer care due to inconsistent skin assessments and documentation. The facility's wound care coordinator admitted to not entering weekly assessments into the clinical record, and the last documented assessment was incomplete. The Director of Nursing confirmed that required weekly assessments had not been completed, leading to the deficiency.
Deficient Continence and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not provided in these areas, indicating lapses in the facility's practices for maintaining continence care, catheter hygiene, and UTI prevention. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Order, Obtain, and Report Laboratory Results as Directed
Penalty
Summary
The facility failed to order and obtain laboratory tests as directed by the physician or nurse practitioner, ensure timely laboratory services, and promptly notify the ordering practitioner of abnormal results for one resident with a change in condition. The resident, who had dementia and required total assistance with activities of daily living, exhibited symptoms including cloudy and discolored urine, increased confusion, and back pain. A nurse practitioner ordered a urine dip and, if positive, further testing, as well as a CBC and CMP. While the urine dip was performed and urine was sent for further analysis, the CBC and CMP were never ordered or resulted. The urinalysis and urine culture, collected on the same day, revealed an abnormal result with a significant presence of E. Coli, but there was no documentation that these abnormal findings were communicated to the physician or nurse practitioner, nor was any treatment initiated for the infection. There was a six-day delay in the laboratory reporting the abnormal urinalysis to the facility, and an additional delay in the facility reporting these results to the physician or nurse practitioner. The abnormal results were only sent to the practitioner the day after they were received by the facility. The facility also lacked a policy or procedure for ordering laboratory tests and reporting abnormal values to the physician. Interviews with the administrator and DON confirmed the absence of such a policy and described inconsistent processes for handling lab orders and results, as well as issues with the contracted laboratory's timeliness.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of unsanitary conditions in the kitchen. During an inspection, dried milk was found on the floor of the walk-in cooler, and the bottom shelf of the Victory freezer was soiled with food spills and debris. The ceiling vent near the ice machine was coated with dust, and the floor beneath the ice machine had a heavy buildup of trash debris and a black, mold-like substance. Additionally, the hand sink next to the Southbend skillet had a hose dripping water onto the floor, which was wet and had a black mold-like substance on the tiles. The flooring under the three-compartment sink was also wet with a similar mold-like substance, and there was a buildup of food debris on the floor in the dry storage room. The trash can for the hand sink was heavily soiled, and numerous small drain flies were observed at the floor drain under the dish machine's soiled drainboard. Furthermore, the facility's staff did not follow proper procedures for measuring food temperatures. Dietary Staff Z was observed using a thermometer to measure the internal temperatures of food items on the steam table without sanitizing the thermometer probe before or between uses. Chef X confirmed that the thermometer should have been cleaned with a probe wipe initially and between each food item. These deficiencies in food safety practices have the potential to result in foodborne illness among residents consuming food from the kitchen.
Facility Assessment Lacks Required Involvement and Input
Penalty
Summary
The facility failed to ensure that the facility-wide assessment was reviewed and revised in accordance with current regulatory requirements, potentially affecting all 117 residents. The assessment, last updated on January 10, 2025, did not include active involvement from the Medical Director, direct care staff, or input from residents, resident representatives, and family members, as required by the revised Facility Assessment requirements effective August 8, 2024. The documentation only included participation from the Administrator, Director of Nursing, Assistant Director of Nursing, Infection Preventionist, Social Services Director, Dietary Manager, Housekeeping/Laundry Manager, and Maintenance Director. During an interview, the Administrator acknowledged the lack of resident and family input and was uncertain about the requirements effective from August 8, 2024, as they had started their role around that time. The Administrator also admitted to not attending resident council meetings due to scheduling conflicts. An updated facility assessment provided by the Administrator still failed to address the concerns of lacking involvement from the Medical Director, direct care staff, and resident input.
Infection Control and EBP Failures
Penalty
Summary
The facility failed to implement and maintain enhanced barrier precautions (EBP) for three residents, which could potentially affect all 117 residents. The infection prevention and control program lacked consistent documentation of signs, symptoms, and laboratory data for infections in January and February 2025. The Infection Control Preventionist (ICP) admitted responsibility for ensuring surveillance completion but relied on floor nurses' documentation, which was insufficient. Resident 53 was observed without EBP signage on their room door, and staff entered the room without sanitizing their hands. The resident had a catheter bag dragging on the floor, and their comprehensive care plan indicated a need for EBP to reduce urinary tract infection risk. The ICP confirmed that EBP signage should have been present, and staff should have sanitized their hands before entering the room. Resident 48 had a urinary catheter and wounds but lacked EBP signage and personal protective equipment (PPE) availability. Staff entered and exited the room without cleaning their hands. The Unit Manager confirmed the resident should have been on EBP but could not explain the lack of implementation. Resident 78 had EBP signage, but the cart outside the room lacked necessary supplies like gloves and hand sanitizer. Staff entered the room without cleaning their hands, and the linen carts throughout the facility were improperly maintained, with non-linen items stored among clean linens.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. A resident was found with a tube of Triad ointment on their bedside table, without any documentation or assessment indicating they were capable of self-administering the medication. The Assistant Director of Nursing confirmed that the resident was unable to apply the ointment themselves and that it should have been stored in the treatment cart. Additionally, multiple medication carts were found with deficiencies. Some carts had drawers that could be opened without unlocking, and insulin pens were found without proper labeling or dating. Food items were improperly stored with medications, and loose pills were found in a medication drawer without identification. The Assistant Director of Nursing acknowledged these issues, noting that medication carts should be reviewed to ensure proper maintenance.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the inconsistent application of protocols for appropriate antibiotic use for three residents. For one resident, there was no documentation of signs and symptoms justifying the need for an antibiotic or the associated lab tests. This resident was also on contact precautions for clostridium difficile, but the antibiotic order was not transcribed correctly upon admission, leading to incomplete treatment. Another resident was prescribed an antibiotic without a start date, and the first dose was not administered. Additionally, a third resident experienced a delay in starting their prescribed antibiotic treatment. During an interview, the facility's infection control preventionist and the Director of Clinical Services acknowledged the lapses in protocol. They confirmed that the necessary labs were not conducted for the first resident, and the antibiotic order for clostridium difficile was incorrectly entered. For the second resident, they recognized the need for a stop date and acknowledged the missed first dose. The infection control preventionist was unsure why the third resident's medication was restarted. These findings indicate a lack of adherence to established protocols for antibiotic use within the facility.
Failure to Provide Water Within Reach for a Resident
Penalty
Summary
The facility failed to ensure that water was provided and kept within reach for a resident, identified as R33, who was reviewed for accommodation of needs. Observations on multiple occasions revealed that R33 was in bed without water within reach, despite a typed note on the bedside table instructing staff to place the tray table above the resident's abdomen for easy access to water. Additionally, a chalkboard message on the bathroom door requested that water be kept within the resident's limited reach of the right hand. The care plan for R33 indicated a decreased ability to self-care and included interventions to keep personal items within reach and encourage the use of the call light for assistance. The Assistant Director of Nursing acknowledged the concern when the issue was shared with them. A policy regarding accommodation of needs was requested but not provided by the end of the survey.
Failure to Honor Resident's DNR Request
Penalty
Summary
The facility failed to honor the end-of-life wishes of a resident, identified as R417, who expressed a desire to change their code status to Do Not Resuscitate (DNR). Despite R417's clear communication of their wishes to not receive Cardiopulmonary Resuscitation (CPR) and their signing of a DNR form, the facility continued to list them as a full code in their medical records. This discrepancy was confirmed during an interview with Nurse N, who stated that CPR would be initiated if R417 became unresponsive, as the resident was still documented as a full code. The delay in updating R417's code status was attributed to the facility's policy, which required a physician's signature to effectuate the change, a process that could take several hours. The Social Work Director and Social Services staff explained that verbal orders were not typically used for advance directives, although the Director of Clinical Services confirmed that nurses could take verbal orders. The facility's Advance Directive Policy indicated that a DNR becomes effective upon signature, yet the policy did not accommodate immediate changes through verbal orders, leading to a failure in promptly updating R417's code status as per their wishes.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to professional standards of practice in medication administration for two residents. For one resident with type 2 diabetes mellitus and diabetic neuropathy, the facility did not document the blood sugar level as required by the physician's orders. The nurse responsible for this resident admitted to obtaining the blood sugar reading but failed to document it on the Medication Administration Record (MAR) at the time it was obtained, as per the facility's protocol. The Assistant Director of Nursing (ADON) confirmed that the blood sugar should have been documented immediately upon obtaining it. For another resident concerned about their blood pressure, the facility did not administer blood pressure medications at the scheduled time. The resident expressed concern about not having their vital signs taken or receiving their blood pressure medications on time. The nurse responsible for this resident admitted to being late in administering the medications, which were scheduled for 9:00 AM but were documented as administered at 10:32 AM. The ADON stated that the facility's protocol allows for medication administration within an hour before or after the prescribed time, and if running late, the nurse should have informed the doctor and management.
Failure to Assist Resident with Oral Care
Penalty
Summary
The facility failed to consistently provide necessary assistance for oral care to a dependent resident, identified as R58, who was unable to perform this activity independently. Observations and interviews revealed that R58, who required staff assistance for all activities of daily living (ADLs) due to conditions such as traumatic subdural hemorrhage, muscle weakness, and dysphagia, was not receiving the needed help with brushing their teeth. R58's daughter expressed concerns about the lack of assistance, noting that R58 could brush their teeth if staff set up the toothbrush and toothpaste. However, staff were not ensuring this assistance was provided, as confirmed by R58 who stated they had not received help with oral care on the mornings observed. Further investigation showed that on one occasion, the Certified Nursing Assistant (CNA) assigned to R58 assumed that the midnight CNA had already assisted R58 with oral care, which was not the case. The Assistant Director of Nursing (ADON) acknowledged that oral care should have been completed when R58 was assisted with getting out of bed and dressed. Despite these acknowledgments, no further explanation or documentation was provided by the facility by the end of the survey, indicating a lapse in the coordination and execution of care responsibilities for R58's oral hygiene needs.
Failure to Implement Timely Treatments and Monitoring
Penalty
Summary
The facility failed to timely implement a prescribed treatment for a fungal rash for a resident, identified as R372. Upon admission, the resident's discharge paperwork from the hospital included a prescription for miconazole nitrate ointment to be applied twice daily to the affected area. However, the facility did not implement this treatment upon admission, and there was no documentation or clarification in the medical record explaining the omission. The ointment was only ordered three days after admission, following a complaint from the resident's husband to the surveyor. Observations confirmed the rash had worsened and spread, indicating a lack of timely care. Another resident, R85, experienced a delay in the implementation of treatment for edema. The resident, who had diagnoses including chronic kidney disease and congestive heart failure, was observed with swollen legs and reported that staff had not been applying the prescribed ACE wraps. The medical record indicated that the wraps were to be applied daily, but documentation showed they were not applied on several occasions. The resident had to undergo extended dialysis to remove excess fluid, and it was revealed that the facility had a shortage of ACE wraps, affecting the resident's care. Additionally, the facility failed to obtain a physician-ordered blood sugar level for resident R48. The resident, who had diabetes and required insulin administration based on blood sugar levels, did not have their blood sugar checked as scheduled. The nurse assigned to the resident was not informed of the resident's request for a blood sugar check, and the task was delayed due to meal tray distribution. The Medication Administration Record lacked documentation of blood sugar results and insulin administration for several days, indicating a lapse in the resident's diabetes management.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to monitor and address significant weight loss for a resident, identified as R23, who experienced a 22.94% weight loss over a period from late October to early December 2024. R23, who was observed to be thin and confirmed their weight loss, had a medical history including moderate protein-calorie malnutrition and chronic kidney disease. Despite these conditions, the facility did not conduct timely nutritional assessments or interventions during the period of significant weight loss. R23's medical records indicated a series of weight measurements showing a drastic decline from 148 lbs on October 30, 2024, to 114.05 lbs by December 2, 2024. The resident was on a minced and moist diet and had a variable appetite, consuming between 25% to 100% of meals. Despite being at nutritional risk due to moderate protein-calorie malnutrition and other factors, there were no dietary assessments or reviews addressing the significant weight loss in November 2024. The facility's registered dietician, RD F, acknowledged the lack of dietary assessments during the critical period in November 2024, attributing it to a transition in dieticians. The facility's policy required monitoring of significant weight changes and assessments by a registered dietician, which were not adhered to in this case. The deficiency was identified during a survey, highlighting the facility's failure to implement timely nutritional interventions for R23's significant weight loss.
Medication Administration Errors Result in 10.34% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10.34% error rate during a medication pass observation. Two residents were affected by these errors. For one resident, Nurse 'U' incorrectly held a 5 mg midorine tablet due to a misunderstanding of blood pressure parameters, despite the resident's blood pressure being recorded as 115/58, which did not meet any specified criteria for withholding the medication. Additionally, Nurse 'U' administered 10 mg of cetrizine, an allergy medication, instead of the prescribed loratidine 10 mg, due to a mix-up in the medication orders. Another resident received a nighttime medication, Atorvastatin 40 mg, in the morning instead of at bedtime as ordered. Nurse E administered the medication in the morning, claiming the order was incorrect and intended to contact the physician for clarification. Furthermore, Nurse E misrepresented the medication as a vitamin to the resident, following a family member's request to prevent medication refusal. These errors were acknowledged by the facility's Assistant Director of Nursing and Administrator during the survey.
Failure to Serve Meals at Desirable Temperatures
Penalty
Summary
The facility failed to ensure meals were served at a desirable temperature, leading to dissatisfaction among residents. Multiple complaints were submitted to the State Agency regarding the palatability of the facility's food. Observations and interviews revealed that residents frequently received meals that were cold, particularly breakfast. For instance, one resident reported that breakfast was always ice cold, prompting their family to bring food from outside. Another resident expressed concerns about cold food during lunch and dinner, and noted that meat was often overcooked and tough. During the survey, a dietary aide was observed delivering food trays, and a test tray review confirmed that some items, such as pancakes and sausage, were ice cold. The Registered Dietician (RD) acknowledged that most residents ate breakfast in their rooms, and trays were prepared in the kitchen before being sent to each unit. However, the RD admitted that staffing challenges sometimes led to the use of carts for delivering meals, which could affect the temperature of the food. The facility's resident council minutes also documented concerns about cold meals, particularly breakfast. The facility's administrator was informed of the concerns regarding cold food and the serving process for residents who preferred to eat in their rooms. Despite requests, the survey team did not receive the facility's policy on food palatability before the survey exit. The report highlights the facility's failure to maintain appetizing temperatures for meals, as evidenced by resident complaints and direct observations of cold food items.
Medication and Treatment Administration Failures
Penalty
Summary
The facility failed to ensure medications and treatments were administered as prescribed, leading to deficiencies in care for three residents. One resident, admitted with a diagnosis including aftercare following surgery and absence of the left leg below the knee, experienced a change in condition with vomiting. Despite receiving a verbal order for a STAT abdominal x-ray and Zofran, the x-ray was not completed, and the Zofran was not administered before the resident left the facility against medical advice. The Director of Nursing (DON) acknowledged the failure to implement the Zofran order and the lack of documentation for the standing order. Another resident, with diagnoses including chronic respiratory failure and COPD, did not receive timely administration of medications and skin treatments. Medication administration audits revealed significant delays, with medications scheduled for 9:00 PM being administered at 2:56 AM, and multiple medications scheduled for 9:00 AM being given at 11:45 AM. Additionally, skin treatments were not applied on several nights as ordered. The DON confirmed that medications should be administered within an hour of the scheduled time and acknowledged the failure to apply skin treatments as ordered. A third resident, with diagnoses including rheumatoid arthritis and depressive disorder, did not receive their physician-ordered pain patch weekly. The resident's clinical record indicated an order for a weekly buprenorphine patch, but the Medication Administration Record showed the patch was only applied once in May. The DON mistakenly believed the order was for a monthly application and could not provide documentation to support this belief. These deficiencies highlight the facility's failure to adhere to physician orders and ensure timely and accurate medication and treatment administration.
Failure to Provide Proper Oxygen Services
Penalty
Summary
The facility failed to provide oxygen services per physician orders for two residents, resulting in significant health issues. One resident was sent to a pulmonologist appointment with an empty oxygen tank, causing their oxygen saturation levels to drop to 80%, which required immediate hospitalization. The resident had a history of rheumatoid arthritis, depressive disorder, and obstructive sleep apnea, and was supposed to receive oxygen continuously at 2 liters per minute. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the incident, noting that the nurse responsible should have ensured the tank was full before the resident left for the appointment. Another resident experienced difficulty breathing due to conflicting supplemental oxygen orders. The resident had chronic respiratory failure, chronic obstructive pulmonary disease, and obstructive sleep apnea. The facility had two oxygen orders in place: one for continuous oxygen at 4 liters per minute and another for CPAP with 3 liters of supplemental oxygen during sleep. The facility's records showed that both orders were signed off as being administered simultaneously, but there was no documentation clarifying which order should have been followed during sleeping hours. The DON and ADON admitted that the orders were not clarified with the physician or coordinated with the respiratory therapist. The facility's failure to ensure proper oxygen administration and coordination of care led to these deficiencies. The lack of communication and verification of oxygen levels before appointments and the failure to resolve conflicting medical orders contributed to the residents' adverse health outcomes. The facility's policy on oxygen administration was not adequately followed, resulting in these critical incidents.
Inconsistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to consistently complete skin assessments and thoroughly document the assessments of existing pressure ulcers for a resident, identified as R702, who was under hospice care. R702 was admitted with diagnoses including Parkinson's Disease and had severely impaired cognition, requiring full assistance for daily activities. The resident had a documented stage 1 pressure ulcer upon admission, but subsequent assessments were not consistently documented in the clinical record. Observations and interviews revealed that R702 was often left in the same position for extended periods, potentially exacerbating pressure ulcer development. The facility's wound care coordinator, RN 'A', admitted to assessing the resident's wounds weekly but had not entered these assessments into the electronic clinical record. The last documented assessment by the former wound care nurse was incomplete, and there was a lack of consistent documentation of the resident's multiple pressure ulcers, which included stage 2 and stage 3 ulcers, as well as a deep tissue injury. The Director of Nursing confirmed that weekly head-to-toe skin assessments were required but had not been completed since early June. Facility policies required that all assessments be entered into the clinical record at the time of assessment, which was not adhered to in this case. The lack of consistent and thorough documentation and assessment of pressure ulcers led to the deficiency noted in the report.
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.
Surveyors found that multiple dependent residents did not receive consistent bathing, hair washing, shaving, or oral hygiene as required by their care plans and ADL needs. One resident with COPD, dementia, and a colostomy went at least 30 days without a documented shower or hair wash and was repeatedly observed with long chin hair despite stating she preferred it shaved. Another hospice resident’s showers and baths were provided only by hospice staff, with no evidence that facility CNAs delivered or documented any bathing during the review period, and hospice documentation was not incorporated into the facility record. A third resident with hemiplegia and major depression was observed with heavy facial hair and plaque on her teeth, reported concerns about shared razors, and had an unused personal electric shaver at bedside, while shower sheets showed no showers or bed baths in 30 days and only two documented refusals without evidence of re-approach or nurse notification.
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.
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 Provide and Document Basic ADL Care for Multiple Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document basic activities of daily living (ADL) care, including bathing, hair washing, shaving, and oral hygiene, for multiple dependent residents. One resident with COPD, dementia, colon cancer with colostomy, anxiety, and depression required substantial to maximal assistance with showering, personal care, toileting, dressing, and transfers per the MDS and care plan. This resident reported that staff only sometimes shaved her facial hair and confirmed she preferred to have her chin shaved, yet surveyors repeatedly observed long chin hairs over several days. Review of the care plan showed she needed physical assistance with personal hygiene and that staff often needed to shave whiskers on her chin. Task sheets and shower documentation revealed no recorded bath or hair wash in the last 30 days, and two shower sheets within that period documented that she was not shaved on either shower day, with no explanation for missed showers or refusals. Further interviews and record reviews showed systemic documentation and scheduling issues contributing to the lack of care. A CNA stated the resident was scheduled for showers twice weekly and that refusals were to be documented on shower sheets and escalated to the nurse, but the facility could not produce adequate shower documentation for the prior 30 days. The DON later explained that CNAs did not know how to enter PRN showers and that when the resident was moved from one bed to another months earlier, her shower task days were not updated, leading CNAs to mark “NA” and follow an outdated schedule. The DON acknowledged that the resident had been moved in June of the prior year and that staff had continued to rely on the old schedule, and also acknowledged that no one had noticed the resident was not receiving showers as ordered. Another resident on hospice services, who was dependent on staff for all ADLs, also did not receive showers or baths from facility CNAs during the review period. Hospice coordination notes showed that a hospice CNA provided showers or baths on several specific dates, but there was no documentation that facility CNAs provided any showers or baths or documented refusals during the last 30 days. The DON stated that hospice admission information and visit notes were sent to the business office and ward clerk and were expected to be scanned into the electronic record or placed in a hospice binder, but record review revealed no hospice documentation in the electronic medical record or paper chart. The hospice binder was instead sitting in someone’s email account, and the DON stated she expected facility CNAs to provide care regardless of hospice involvement. A third resident with hemiplegia, muscle disorder, cervical disc disorder, fistula, difficulty walking, and major depression was dependent for all ADLs and was observed with visible plaque buildup on her teeth and heavy facial hair on her chin and upper lip. She reported that she had asked staff to shave her facial hair but was told the same razor was used on multiple residents, leading her to refuse that method and have her husband bring in an electric razor, which remained unused on her overbed table for at least a day. A CNA confirmed that the resident had not had her facial hair shaved until that point and that she was scheduled for a bed bath that day. The care plan directed staff to shave her face as needed and to encourage her to allow shaving, and there was no care plan entry stating she did not want her facial hair shaved. Shower sheets listed her for showers/bed baths twice weekly, but documentation showed no showers or bed baths in the last 30 days, with only two dates marked as refusals and no evidence of re-approach or nurse notification. The DON stated the expectation was twice-weekly showers or bed baths and acknowledged that refusals were only documented on two dates, with no corresponding progress notes showing re-approach or nurse follow-up, aside from a single progress note where the resident refused shaving with no documented follow-up.
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.
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