Regency At Bluffs Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Ann Arbor, Michigan.
- Location
- 355 Huronview Blvd, Ann Arbor, Michigan 48103
- CMS Provider Number
- 235658
- Inspections on file
- 22
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Regency At Bluffs Park during CMS and state inspections, most recent first.
A resident with hypotension, muscle wasting, poor strength and balance, and documented dizziness and lightheadedness had a care plan and therapy-to-nursing instructions requiring substantial/maximal assist of two staff, use of a sit-to-stand lift for transfers, and ambulation with a rolling walker in therapy only. Despite this, a CNA assisted the resident out of bed and ambulated him to the bathroom with only a walker and grippy socks, without a gait belt, without a second staff member, and without checking the Kardex. While the CNA turned to open the bathroom door, the resident fell backward, was initially unresponsive, and was later found to have multiple skull fractures, subdural hematoma, and brain compression. Interviews showed that some nursing staff believed the resident was a one-person assist and were unaware of recent hypotension and dizziness, while the DON confirmed that the care plan and Kardex requiring two-person assist and sit-to-stand lift were not followed, and the death certificate attributed death to complications of blunt force head trauma from the fall.
A resident with hypotension, muscle wasting, liver cell carcinoma, impaired balance, and documented lower extremity impairment had a care plan and Kardex indicating substantial/maximal assist with two staff, use of a sit-to-stand lift for transfers, wheelchair for ambulation, and ambulation with a rolling walker in therapy only due to poor strength, balance, and fall risk. A CNA, without checking the Kardex, assisted the resident out of bed using only a walker and grippy socks, with standby assist and no gait belt or lift, and attempted to walk the resident to the bathroom. When the CNA turned to open the bathroom door, the resident fell backward, was initially unresponsive, and was later found to have skull fractures and a subdural hematoma with brain compression. The death certificate listed complications of blunt force head trauma from a fall at the nursing home as the immediate cause of death, and interviews with staff and the DON confirmed that the resident’s care plan was not followed and that nursing staff had ambulated the resident despite the documented restrictions.
Surveyors found that food service equipment, including a juice machine, stove/oven, can opener, mixer table, and refrigerator, was not properly cleaned and had accumulated food residue. Additionally, the dish machine was operating below required sanitizing temperatures, and some equipment was in disrepair, such as loose stove handles and a leaking sink faucet. These deficiencies affected 58 residents and increased the risk of cross-contamination and bacterial growth.
Surveyors identified widespread deficiencies in cleaning and maintenance, including soiled ventilation grills, damaged chairs exposing inner padding, and missing or broken atmospheric vacuum breakers in multiple areas. These issues were not documented in the facility's maintenance work order system, despite policies requiring ongoing monitoring and cleaning.
Multiple residents and their families reported incidents where staff denied timely toileting assistance, made dismissive remarks, or failed to provide appropriate care, resulting in emotional harm and humiliation. Despite these grievances, facility leadership did not recognize or report these events as abuse or neglect to the state agency, instead treating them as customer service issues and failing to follow required abuse reporting protocols.
Multiple residents reported grievances involving staff telling them to use the bathroom in their briefs, denying assistance with toileting, and making dismissive remarks. These complaints were not recognized as potential abuse or neglect, and no investigations were conducted. Instead, the facility treated the issues as customer service concerns, resulting in emotional distress and a lack of appropriate follow-up for the affected residents.
Multiple residents experienced significant delays in call light response and pain medication administration due to insufficient nursing staff, with CNAs and LPNs reporting unmanageable workloads and inability to take breaks. Residents described waiting up to an hour for assistance, and staff acknowledged instructing residents to use briefs instead of providing timely toileting help. These staffing shortages led to ongoing concerns about unmet care needs and delays in essential services.
A resident with cognitive impairment was found resting in bed with un-bagged, feces-smeared linen placed on a pillow on a nearby recliner, just a few feet from their face. The soiled linen remained there for over 30 minutes. Staff interviews confirmed that protocol requires immediate bagging and removal of soiled linen, and that leaving it un-bagged on resident furniture is not acceptable.
Three residents experienced emotional distress after being told by CNAs to use the bathroom in their briefs due to staff time constraints, rather than being assisted to the toilet or offered their own underwear. These incidents, which were documented in grievances and confirmed by facility leadership, resulted in feelings of embarrassment, humiliation, and being devalued.
A resident with cognitive intactness and mobility issues experienced multiple room changes without receiving advance written notice as required. Documentation showed only two notifications for four room changes, and the social worker was unable to locate the missing notifications.
A resident with muscle wasting, atrophy, and anoxic brain damage, who was cognitively intact but dependent on staff for transfers and had limited hand use, was observed using a seatbelt on a motorized wheelchair that he could not independently release. Staff confirmed the resident's inability to unlatch the seatbelt, and no prior assessment of the seatbelt as a physical restraint was documented until after surveyor intervention.
A resident with mobility difficulties and intact cognition experienced missed and inappropriately timed showers due to frequent room changes and poor communication from staff. Showers were sometimes offered late in the evening or after dressing changes, leading to refusals, and documentation of refusals was inconsistent with facility expectations.
A resident with severe physical limitations fell and sustained a head injury after being transferred to a motorized wheelchair with the armrest left up. Staff involved in the transfer were not adequately trained on the resident's specific needs, and the resident was left unsupervised, resulting in the fall.
A resident with a history of spinal fusion and dialysis dependence did not receive Occupational Therapy (OT) services as ordered, with therapy staff citing scheduling conflicts and staffing shortages. Despite physician orders and an OT evaluation specifying frequent therapy, the resident went several days without receiving OT, as confirmed by service logs and staff interviews.
Staff did not consistently follow PPE protocols and hand hygiene practices for residents on Transmission-Based Precautions. For example, a resident on droplet precautions for suspected COVID-19 was cared for by staff who failed to wear required eye protection and did not remove masks as per protocol. Additionally, an LPN did not perform hand hygiene before or after medication administration, nor did he change his mask when required, including when caring for a resident on contact precautions for COVID-19.
The facility did not implement an effective QAPI plan to address allegations of abuse from resident grievances. Fifteen grievances were not identified as abuse, and the QAPI committee did not discuss or recognize these concerns, despite policy requiring review of resident concern logs.
A resident, admitted five days prior and cognitively intact, did not receive necessary oral care supplies, despite documentation indicating oral care was completed. The resident reported not having a toothbrush, toothpaste, or mouthwash since admission. A CNA was unable to locate these supplies in the resident's room, and the DON stated that new admissions should receive basic ADL supplies, including oral care items.
A resident with a history of cardiac and respiratory issues experienced a drop in oxygen levels, which was not followed up by the nursing staff. Despite alerts for low oxygen levels, there was no documented assessment or notification to the physician, leading to the resident being found unresponsive and requiring hospital transfer.
A facility failed to follow physician orders for a resident with urine retention, requiring bladder scans every six hours and catheterization if post-void residual exceeded 250 mL. Records showed multiple instances of non-compliance, with scans not completed and catheterizations performed without necessary results or below the threshold. The resident, cognitively intact, reported staff not performing scans before catheterization, confirmed by the DON.
A facility failed to notify a physician of abnormal urine culture results for a resident with urine retention. The resident's urinalysis showed a pending culture, and a Nurse Practitioner noted the positive urinalysis but awaited culture results as the resident was asymptomatic. The culture, positive for Klebsiella pneumoniae and E. coli, was not obtained until much later, with no documentation of physician notification or acknowledgment.
A facility failed to document urine culture results in a resident's medical record. The resident, admitted with urine retention, had a urinalysis indicating a pending culture. Despite a positive urinalysis noted by an NP, the culture results were not recorded. The results, showing Klebsiella pneumoniae and E. coli, were only retrieved months later upon request. The DON noted the use of a separate system for lab results.
The facility failed to maintain sanitary conditions in the kitchen, as dietary staff did not use hand barriers to shut off faucets after washing their hands. This non-compliance with the hand hygiene policy and the U.S. Public Health Service 2017 Food Code increased the potential for cross-contamination and foodborne illness, affecting 54 residents who receive meal services.
The facility failed to provide sufficient staff to meet residents' needs, resulting in delayed call light responses and unmet care needs. Multiple residents and family members reported long wait times for assistance, with some residents experiencing significant delays in receiving help for toileting and other needs. Language barriers further exacerbated the issue for non-English speaking residents.
The facility failed to maintain a safe, functional, and sanitary environment for 56 residents and staff. Dust and debris were found in the dietary storage closet, physical therapy cold compresses were stored in a food-designated freezer, and lift batteries and charging stations were kept in soiled utility rooms. The Housekeeping Supervisor acknowledged the improper storage and agreed to relocate the items.
The facility failed to maintain the dignity of two residents, leading to feelings of frustration and decreased self-worth. One resident was left without assistance after attempting to communicate in a different language, while another had to wait up to an hour for help and was dismissed when calling out for assistance.
A resident experienced dissatisfaction and reduced independence due to the facility's failure to provide timely repair services for her power wheelchair. Despite notifying the social worker months ago, no follow-up was conducted, and the issue was only recently addressed by the new Therapy Director and Social Worker. The Director of Nursing acknowledged the delay and lack of communication among staff.
The facility failed to accurately complete MDS assessments for two residents, leading to potential inaccuracies in care plans. One resident with profound hearing loss was documented as having adequate hearing, and another resident with severe mental illness was incorrectly coded as not having a serious mental illness. These errors were acknowledged by the social worker.
A resident with multiple medical conditions and a language barrier experienced repeated falls due to the facility's failure to implement comprehensive care plans and ensure effective communication. The resident's call light was often out of reach, and staff were unsure about using translation services, leading to unmet care needs and continued falls.
A resident with multiple medical conditions and a primary language of Romanian experienced repeated falls and unmet needs due to the facility's failure to utilize available translation services and communication tools. Staff were observed and interviewed, revealing a lack of awareness and use of these services, leading to significant deficiencies in care.
The facility failed to ensure appropriate contracture management for a resident with multiple medical conditions, including an amputation and acquired club foot. Despite physician orders and POC documentation for daily ROM exercises, there was no documentation of completion or refusal for the last 30 days. Staff interviews revealed that the resident had refused ROM in the past, leading to a lack of follow-through on prescribed exercises.
A resident with multiple diagnoses experienced recurrent falls due to the facility's failure to consistently follow care plan interventions and address communication barriers. Despite having a care plan that included non-skid footwear, call light accessibility, and two-hour toileting, the resident's falls continued. The resident's language barrier further complicated effective communication, and staff did not consistently use available translation services or communication tools.
The facility failed to administer pain medications as ordered for two residents, resulting in increased pain and unmanaged pain. One resident experienced frequent delays in receiving Morphine Sulfate ER, while another faced severe pain and withdrawal symptoms due to delays in receiving Fentanyl and Gabapentin. Staff acknowledged the deficiencies and the lack of proper documentation.
The facility failed to ensure proper storage of medications for two residents, leading to potential unauthorized access and medication errors. One resident was found with inhalers on her bed, and another with inhalers and eye drops on her windowsill. Both residents did not have completed assessments for self-administration, and their medications were not stored in a lockbox as required.
The facility failed to justify the use of an antipsychotic medication for a resident with visual hallucinations, adjustment disorder with depressed mood, and dementia. Despite multiple dose reductions and recommendations for further GDRs, the facility did not document adequate indications for the medication's use, nor did they attempt further GDRs. Interviews with staff revealed inconsistencies in the documentation and monitoring of the resident's symptoms.
Failure to Follow Care Plan and Therapy Restrictions Leads to Fatal Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent a fall and follow the resident’s care plan and therapy-to-nursing instructions, resulting in a major injury. The resident was admitted with diagnoses including hypotension, muscle wasting and atrophy, malaise, and liver cell carcinoma. An MDS assessment showed intact cognition but documented lower extremity impairment on one side and a need for substantial/maximal assistance for bed mobility and sit-to-stand, and dependence for toilet transfers and walking 10 feet. Therapy evaluations and progress notes documented poor strength and balance, generalized weakness, dizziness, lightheadedness, episodes of hypotension, and a need for maximal assistance of two staff for transfers, sit-to-stand, and ambulation. Therapy-to-nursing communication and the care plan specified that ambulation with a rolling walker was to occur in therapy only, that transfers required two-person substantial/maximal assistance with a sit-to-stand lift, and that toilet transfers required substantial/maximal assistance. Despite these documented needs, on the morning of the fall the resident’s call light was answered by a CNA who assisted the resident out of bed and ambulated him to the bathroom using only a walker and grippy socks, without a gait belt or sit-to-stand lift, and without a second staff member. The CNA reported that she did not check the Kardex for the resident’s required level of assistance because she had taken care of him before and did not think to check, even though she was aware that the Kardex should be used to determine assistance levels. While the resident was standing and the CNA turned away to open the bathroom door, she heard a loud sound and turned back to find the resident on the floor on his back and initially unresponsive. The incident report and nursing notes documented that the resident fell flat on his back while transferring to the bathroom, went unconscious, and was later noted to be lethargic with nonreactive pupils and a high PAINAD score indicating significant pain behaviors. Clinical records and interviews further showed that nursing staff were not consistently aware of or following the resident’s documented risks and limitations. Physical therapy notes recorded very low blood pressure readings in standing and sitting, and the nurse practitioner documented generalized weakness, gait instability, dizziness, and lightheadedness, with orthostatic vital signs later confirming significant blood pressure changes with position. A floor nurse who had previously cared for the resident stated that he walked with two staff and a walker and needed more assistance getting off the toilet, but the nurse on duty at the time of the fall believed the resident was a one-person assist and was unaware of recent dizziness or low blood pressure. The DON confirmed that the care plan and Kardex required two-person assistance, sit-to-stand lift for transfers, and ambulation with therapy only, and that the resident had been ambulated by nursing staff contrary to these directives. The fall resulted in multiple skull fractures, subdural hematoma, brain compression, and was listed on the death certificate as complications of blunt force head trauma from a fall in the nursing home.
Failure to Follow Care Plan for High-Risk Resident During Ambulation and Toilet Transfer
Penalty
Summary
The deficiency involves the facility’s failure to follow an existing care plan for a resident with significant functional limitations and identified fall risk. The resident was admitted with diagnoses including hypotension, muscle wasting and atrophy, malaise, and liver cell carcinoma, and had intact cognition per an MDS assessment. The MDS and therapy assessments documented lower extremity impairment, a need for substantial/maximal assistance for bed mobility and sit-to-stand, dependence for toilet transfers and walking, and poor strength and balance. Therapy-to-nursing communication and the Kardex specified that the resident required substantial/maximal assistance, use of a sit-to-stand lift for transfers, wheelchair for ambulation, and that ambulation with a rolling walker was to occur in therapy only due to the level of assistance and safety cues required. Despite these documented needs and care plan interventions, on the morning of 11/15/2025 a CNA responded to the resident’s call light and assisted the resident out of bed using only a walker and grippy socks, without a gait belt or other assistive devices, and without checking the Kardex. The CNA attempted to walk the resident to the bathroom with standby assist, turned away to open the bathroom door, and then heard a loud sound. When she turned back, the resident was found on the floor on his back and initially unresponsive. The incident report and subsequent interviews confirmed that the resident had been ambulated by nursing staff, contrary to the care plan that required two-person substantial/maximal assistance with a sit-to-stand lift for transfers and specified that ambulation with a rolling walker was to occur in therapy only. Following the fall, the resident was noted to have a high PAINAD score with signs of pain, lethargy, and injuries including a skull fracture and subdural hematoma with brain compression. The death certificate later documented the immediate cause of death as complications of blunt force head trauma from a fall, with the place of injury identified as the nursing home. Interviews with the CNA, an LPN, and the DON confirmed that staff were expected to use the care plan or Kardex to determine required assistance levels, that the care plan was not followed at the time of the incident, and that the resident had previously ambulated with nursing staff despite the documented restrictions and identified fall risk.
Failure to Maintain and Sanitize Food Service Equipment
Penalty
Summary
Surveyors observed multiple instances of inadequate cleaning and maintenance of food service equipment affecting 58 residents. During an initial tour of the kitchen, several pieces of equipment, including the juice machine, Vulcan stove/oven, can opener assembly, stand mixer support table, and refrigerator, were found with accumulated and encrusted food residue. The stove/oven door handles were also noted to be loose, and the food preparation sink faucet assembly was leaking and could not be fully shut off. These conditions were confirmed by the Dietary Manager, who acknowledged the need for cleaning and repairs. Further review revealed that the mechanical dish machine's wash temperature was below the required standard, with a digital display reading 130.1°F during the cleaning cycle, which does not meet the minimum temperature requirements for effective sanitization as outlined in the FDA Model Food Code. The Registered Dietician confirmed that the facility had a contractual service for maintaining the dish machine. Policy and procedure documents reviewed indicated that malfunctions and repair needs should be reported promptly to maintenance and the administrator, and that cleaning and sanitizing of food contact surfaces should occur after each use and when contamination is possible. Despite these policies, the observed conditions demonstrated a failure to maintain food service equipment in a clean and sanitary state, as well as a failure to ensure timely repairs and proper functioning of essential kitchen equipment. These deficiencies increased the likelihood of cross-contamination and bacterial harborage, directly impacting the safety and quality of food served to residents.
Failure to Maintain Cleanliness and Physical Plant Integrity
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 60 residents. During an environmental tour, multiple areas were observed with soiled and encrusted dust/dirt deposits on return-air-exhaust ventilation grills, including shower rooms, staff and public restrooms, and resident rooms. Additionally, several chairs in common areas and resident rooms were found to be damaged, with surfaces etched, scored, and exposing inner Styrofoam padding. In the kitchen storage room, a broken atmospheric vacuum breaker was noted on the mop sink faucet assembly, and several shower wand assemblies in resident rooms were missing atmospheric vacuum breakers. Interviews with the Maintenance Director revealed that the facility uses the TELS system for maintenance work orders. However, a review of the TELS work orders for the past 60 days showed no specific entries related to the observed maintenance concerns. The facility's policies for maintenance and housekeeping require ongoing monitoring and thorough cleaning of environmental surfaces, but these procedures were not followed as evidenced by the observed deficiencies. The lack of effective cleaning and maintenance increased the likelihood of cross-contamination, bacterial harborage, reduced air quality, and potential cross-connections between potable and non-potable water supplies. The findings were based on direct observations, interviews, and record reviews, with no documentation indicating that the identified issues had been previously addressed through the facility's maintenance system.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, or mistreatment for 14 residents were reported to the state agency as required. Multiple grievances were filed by residents and their family members, describing incidents where staff told residents to use the bathroom in their briefs or diapers due to lack of time, denied assistance with toileting, or made dismissive and inappropriate remarks. In several cases, residents reported feeling humiliated, degraded, or emotionally harmed by these interactions. Some residents also described being denied showers, not being offered the option to wear their own underwear, or being left without timely care for personal needs. Despite these grievances, the facility's administrative staff, including the administrator and DON, did not identify these incidents as allegations of abuse. Instead, they categorized them as customer service or care concerns and addressed them through staff education or reassignment, without reporting them to the state agency as required by policy. The facility's grievance policy specified that concerns related to alleged abuse, neglect, or mistreatment should be immediately forwarded to supervisory staff, but this procedure was not followed in these cases. Interviews with the administrator and DON confirmed that they were aware of the grievances and the nature of the complaints but did not consider them to be abuse. As a result, none of the allegations were reported to the appropriate authorities, and the required investigation and reporting process was not initiated. The failure to recognize and report these allegations represents a breakdown in the facility's abuse reporting protocol and a violation of regulatory requirements.
Failure to Identify and Investigate Allegations of Abuse
Penalty
Summary
The facility failed to identify and investigate allegations of abuse for 14 out of 14 residents who reported grievances that included potential abuse or neglect. Multiple residents and their family members submitted grievances describing incidents where staff told them to use the bathroom in their briefs or diapers due to lack of time, denied assistance with toileting, or made dismissive and inappropriate remarks. In several cases, residents reported being humiliated, embarrassed, or feeling like they were not cared for, and some described being forced to self-transfer or forego showers and personal care due to staff inaction. Despite these grievances, the facility did not recognize the complaints as potential abuse or neglect, and no formal investigations were conducted. Instead, the facility treated these reports as customer service or staffing issues, providing staff education or reassigning staff without initiating abuse protocols. In some cases, there was no documented resolution at all. The administrator and DON both confirmed in interviews that they did not consider these grievances as allegations of abuse, even when residents described psychosocial harm or direct statements from staff instructing them to soil themselves due to lack of assistance. The affected residents included individuals who were cognitively intact and able to articulate their needs and experiences, as well as those who required assistance with activities of daily living. Several residents expressed emotional distress, humiliation, and a loss of dignity as a result of staff actions and the facility's failure to respond appropriately. The lack of investigation into these allegations represents a failure to protect residents from potential abuse and to comply with regulatory requirements for reporting and investigating such incidents.
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. Certified Nurse Aides (CNAs) reported being assigned up to 16 or more residents per shift, with their ability to keep up with care dependent on resident acuity. Several residents reported waiting 30 to 60 minutes or longer for staff assistance, particularly for pain medication and call light responses. One resident, who had a history of spinal fusion and was dependent on renal dialysis, reported multiple instances of waiting 45 minutes or more for pain medication, and another resident described similar delays during overnight hours. Residents also reported that delays in care negatively impacted their physical therapy progress and caused concerns about timely assistance during emergencies. Staff interviews corroborated these concerns, with CNAs and LPNs stating that the facility was understaffed and that it was difficult to find assistance for two-person transfers. CNAs reported being unable to take breaks due to staffing shortages and described being responsible for up to 30 residents when coworkers were unavailable. Some staff admitted to instructing residents to use the bathroom in their briefs as a time-saving measure. Residents and staff consistently reported that call light response times were inadequate, and these issues were repeatedly raised in Resident Council meetings without resolution.
Failure to Maintain Resident Dignity by Improper Handling of Soiled Linen
Penalty
Summary
A deficiency was identified when a resident with a compression fracture and moderate cognitive impairment was observed resting in bed with a pile of un-bagged, feces-smeared linen placed on a pillow on a recliner chair approximately 2 to 3 feet from the resident's face. The soiled linen remained in this position for at least 31 minutes. Interviews with a CNA and the Director of Nursing confirmed that facility protocol requires soiled linen to be immediately bagged and taken to the soiled utility room, and that there is no acceptable reason for soiled linen to be left un-bagged or placed on resident furniture. The incident occurred due to a failure to follow established procedures for handling soiled linen, resulting in a lack of dignity for the resident.
Failure to Maintain Resident Dignity and Honor Personal Preferences
Penalty
Summary
The facility failed to honor the dignity and personal preferences of three residents by not offering them the choice to use their own underwear instead of briefs, and by instructing them to use the bathroom in their briefs due to staff time constraints. One resident, who was cognitively intact and ambulatory with a walker, reported never being offered his own underwear, despite having several pairs in his dresser. He expressed embarrassment and distress at being made to wear briefs, which he did not use prior to admission, and recounted an incident where a CNA told him to have a bowel movement in his brief because staff did not have time to assist him to the toilet. Another resident reported a similar experience, stating that a CNA told her to use the bathroom in her brief due to lack of time. This resident had also filed a grievance about the incident, which was documented as a customer service issue rather than an allegation of abuse. The administrator and DON confirmed awareness of these grievances and acknowledged that staff had told residents to use their briefs when assistance was requested but not provided. A third resident, who was cognitively intact and required assistance for transfers, reported long call light response times and being told to have a bowel movement in his brief while in bed. This resident described the experience as humiliating and degrading, and subsequently began self-transferring to the bathroom to avoid similar incidents. He also filed a grievance regarding the incident but reported no appropriate follow-up or resolution. All three residents experienced emotional distress, including feelings of anger, embarrassment, and being devalued.
Failure to Provide Advance Written Notice for Room Changes
Penalty
Summary
The facility failed to provide advanced written notice prior to a room change for one resident. The resident, who was cognitively intact and had difficulty walking, reported experiencing several room changes without prior notification, with staff typically informing her of the move on the same day it occurred. Record review confirmed that the resident had four room changes since admission, but only two written notifications were documented. The social worker confirmed that staff are expected to inform residents and document these conversations, but was unable to locate the missing notifications for two of the room changes.
Failure to Assess Wheelchair Seatbelt as Potential Physical Restraint
Penalty
Summary
A deficiency occurred when the facility failed to assess whether a seatbelt used by a resident in a motorized wheelchair constituted a physical restraint. The resident, who had diagnoses including muscle wasting, atrophy, and anoxic brain damage, was cognitively intact but dependent on staff for transfers and had limited use of only one hand. Observations and interviews confirmed that the resident was unable to independently release the seatbelt and had never been asked if he could do so. Certified Nursing Assistants and the Therapy Director confirmed the resident's inability to unlatch the seatbelt. Although the Therapy Director reported that a physical restraint evaluation had been completed, no documentation could be found until after surveyor intervention, at which point an evaluation and a physician order for the seatbelt were created.
Failure to Offer and Complete Showers per Resident Preference
Penalty
Summary
The facility failed to ensure that showers were offered and completed according to the preferences of a resident who was unable to perform activities of daily living independently. The resident, who was cognitively intact and had difficulty walking, reported experiencing multiple room changes without prior notice, which led to confusion about her scheduled shower days. As a result, she missed some scheduled showers and was offered showers at inconvenient times, such as late in the evening or after dressing changes, leading to refusals. The resident was unsure of her current shower schedule and denied refusing showers except when they were offered at unreasonable times. Documentation review showed several instances where the resident either refused showers due to lack of advance notice or because the timing was inappropriate. In some cases, refusals were not properly documented, and staff marked 'no' in the shower task without following the expected documentation process. The Director of Nursing confirmed that staff are required to document refusals in the medical record or on a shower sheet and that showers should be offered according to the established schedule.
Failure to Prevent Fall Due to Improper Wheelchair Transfer
Penalty
Summary
A deficiency occurred when staff failed to prevent a fall for a resident with significant physical impairments, including muscle wasting, atrophy, anoxic brain damage, and no trunk control. The resident was dependent on two staff members and a mechanical Hoyer lift for transfers and required the armrests of his motorized wheelchair to be down for safety. On the day of the incident, after being transferred to his wheelchair, the left armrest was left up, and the staff member left the room. As a result, the resident fell sideways out of the chair and sustained a head injury, requiring hospital transfer. The incident report confirmed that the fall was due to the armrest being left up during the transfer. Interviews with staff revealed that the CNA assisting with the transfer was not adequately trained on the specific requirements for transferring this resident into the motorized wheelchair, particularly regarding the necessity of ensuring the armrests were down. The CNA also indicated that she was assigned to a different hall and had to leave the room due to other duties, which contributed to the lack of supervision. The Director of Nursing confirmed that the fall occurred because the armrest was not down and the resident lacked core strength, leading to the accident.
Failure to Provide Ordered Occupational Therapy Services
Penalty
Summary
A deficiency was identified when a resident with a history of spinal fusion and dependence on renal dialysis did not receive Occupational Therapy (OT) services as ordered. The resident was admitted and readmitted to the facility, and their physician orders specified OT services six times per week for 12 weeks, while the OT evaluation indicated five times per week for 12 weeks. The resident reported receiving less therapy than ordered and expressed concern about being considered for discharge due to lack of progress, attributing this to insufficient therapy sessions. Observations confirmed the resident was wearing a cervical collar and was in bed at the time of review. Interviews with therapy staff revealed that therapy sessions were sometimes missed due to the resident's dialysis schedule and staffing limitations, with attempts made to adjust therapy around these constraints. The Therapy Director confirmed that OT services had not been provided since a specific date, despite the resident remaining on the OT caseload. Review of the OT Service Log corroborated that no OT services had been delivered for several days, indicating a failure to provide specialized rehabilitative services as required by the resident's care plan and physician orders.
Failure to Ensure Proper PPE Use and Hand Hygiene During Transmission-Based Precautions
Penalty
Summary
Staff failed to ensure proper use of Personal Protective Equipment (PPE) and hand hygiene for residents on Transmission-Based Precautions (TBP). In one instance, a resident with a history of chronic obstructive pulmonary disease and recent testing for COVID-19 was placed on droplet precautions. Observations revealed that staff members entered the resident's room wearing gowns, gloves, and N95 masks, but did not wear required eye protection. One staff member exited the room wearing both an N95 and a surgical mask, walked through the hallway without removing the masks as required, and later returned to the room with a face shield but only a surgical mask. The Director of Nursing confirmed that the facility's protocol required a gown, gloves, N95 mask, and face shield to be worn, with removal of gown and gloves before exiting and removal of the N95 mask immediately upon exit. The resident was not informed about the reason for TBP, and isolation was discontinued after a negative COVID-19 test. Additional observations showed that an LPN did not perform hand hygiene before or after administering medications to residents, including one on contact precautions for COVID-19. The LPN donned a gown and gloves but did not change or remove his surgical mask as required, and failed to perform hand hygiene before donning gloves, contrary to posted recommendations. These actions did not follow the facility's policy and procedures for PPE use and hand hygiene, increasing the risk of cross-contamination.
Failure to Address Abuse Allegations in QAPI Process
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement Committee (QAPI) plan to address allegations of abuse arising from resident grievances. Review of resident concern and grievance logs showed that, since June 2024, there were 15 grievances from 15 residents that were not identified as allegations of abuse. According to the facility's QAPI policy and procedure, resident concern summary logs were to be used for identifying improvement priorities, but these logs were not utilized to identify abuse concerns. During an interview, the administrator confirmed that the QAPI committee met monthly with all required members present, but no performance improvement plans were in place, and allegations of abuse had not been recognized as a concern by the committee. Review of the most recent QAPI meeting minutes showed no discussion or identification of abuse allegations, despite the presence of multiple resident concerns in the logs.
Failure to Provide Oral Care Supplies to Resident
Penalty
Summary
The facility failed to provide necessary oral care supplies to a resident, identified as R5, who was admitted five days prior and was cognitively intact with a Brief Interview Status (BIMS) score of 15 out of 15. Despite being documented as having completed oral care, R5 reported not receiving a toothbrush, toothpaste, or mouthwash since admission. Observations confirmed R5's claim, as they were seen self-ambulating and sitting on the edge of their bed without having received the necessary supplies. A Certified Nursing Assistant (CNA) believed R5 had the supplies but was unable to locate them in R5's room. The Director of Nursing (DON) stated that new admissions should receive a basin with basic ADL supplies, including oral care items.
Failure to Follow Up on Resident's Low Oxygen Levels
Penalty
Summary
The facility failed to follow up on a change in vital signs for a resident (R2) who was admitted with diagnoses including infection and inflammatory reaction due to cardiac and vascular devices, COPD, history of cardiac arrest, and acute respiratory failure with hypoxia. On 7/12/24, R2's oxygen level was documented as 90% at 9:00 AM, but later in the day, it dropped to 85% and then to 83% without any documented follow-up or assessment by the nursing staff. RN C, who worked the day shift, reported not being aware of the oxygen level below 90% and did not document any assessment or notify the physician. The medical record lacked documentation of any intervention or notification to the physician regarding the low oxygen levels. Later that evening, LPN D found R2 unresponsive with an oxygen level of 83% and other vital signs indicating distress. Oxygen was administered, and R2 was transferred to the hospital. Interviews with staff revealed that the facility's system alerted CNAs of abnormal vital signs, which should have been reported to the nurse and then to the physician. However, there was no evidence that this protocol was followed, leading to a lack of timely intervention for R2's declining condition.
Failure to Follow Physician Orders for Bladder Scans and Catheterization
Penalty
Summary
The facility failed to adhere to physician orders for a resident who was admitted with a diagnosis of urine retention. The orders required bladder scans every six hours and intermittent straight catheterization if the post-void residual was greater than 250 mL. However, the medical records revealed multiple instances where bladder scans were not completed as ordered, and catheterizations were performed without the necessary bladder scan results or when the results were below the threshold for catheterization. This inconsistency in following the physician's orders was confirmed by the Director of Nursing during an interview. The resident, who was cognitively intact, reported instances where nursing staff did not perform bladder scans before catheterization, contrary to the physician's orders. The Medication Administration Records further documented several occasions where the bladder scans were either not completed or the catheterization was performed despite the scan results being below the required threshold. These actions indicate a failure to provide appropriate care as per the physician's directives, leading to the deficiency noted in the report.
Failure to Notify Physician of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to notify the physician of urine culture results for a resident who was admitted with a diagnosis of urine retention. The resident, who was cognitively intact, had a urinalysis on 6/3/24, which showed a pending urine culture. On 6/4/24, a Nurse Practitioner noted the urinalysis was positive for leukocyte esterase and decided to await the culture results as the resident was asymptomatic. However, the urine culture results, which were positive for Klebsiella pneumoniae and Escherichia coli, were not obtained from the laboratory until 2/4/25. There was no documentation in the resident's medical record indicating that the physician was notified of these abnormal results or that the physician acknowledged them. The Director of Nursing confirmed that there was no evidence of physician notification or review of the urine culture results.
Failure to Document Urine Culture Results
Penalty
Summary
The facility failed to ensure that urine culture results were included in the medical record for a resident who was admitted with a diagnosis of urine retention. The resident, who was cognitively intact, had a urinalysis on 6/3/24 that indicated a pending urine culture. A Nurse Practitioner noted on 6/4/24 that the urinalysis was positive for leukocyte esterase and that they would await the culture results, as the resident was asymptomatic. However, the urine culture results, which were positive for Klebsiella pneumoniae and Escherichia coli, were not documented in the resident's medical record. The results were only obtained from the laboratory on 2/4/25 after being requested by the Nursing Home Administrator. The Director of Nursing reported that the culture results could not be located in the medical record and mentioned that physicians used a separate system for laboratory results.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which increased the potential for cross-contamination of food and foodborne illness. This deficiency was observed through multiple instances where dietary staff, including a dietary aide, a chef, and a registered dietitian, did not use a hand barrier to shut off the faucet after washing their hands. These observations were made on several occasions, indicating a pattern of non-compliance with the facility's hand hygiene policy and the U.S. Public Health Service 2017 Food Code, which requires the use of disposable paper towels or similar clean barriers to avoid recontaminating hands after washing. The facility's hand hygiene policy was reviewed and confirmed to be in place, outlining the proper procedure for handwashing. Despite this, staff members were observed not adhering to the policy, even though the dietary manager confirmed that training had been conducted and signs were posted at sinks. The failure to follow proper hand hygiene procedures potentially affected the facility's total census of 54 residents who receive meal services, increasing the risk of foodborne illness among the residents.
Insufficient Staffing and Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of residents, as evidenced by multiple resident and family interviews. Resident #19 reported that despite communicating her preference to be up by 10:00 AM, she often had to wait until 11:00 AM or later for assistance. Additionally, she experienced delays in receiving help to use the bathroom, having to wait from 1:00 PM to 1:40 PM on one occasion. Resident #41 and her family member expressed concerns about longer call light response times, particularly on weekends. Resident #42, who required assistance with ambulation and toileting, was observed waiting for nearly an hour for help to use the bathroom, with staff unable to communicate effectively due to a language barrier. Resident #50 reported waiting up to an hour for call light responses and, on one occasion, had to yell for help because his call light was not within reach. He also experienced staff dismissing his calls for assistance. Resident #323, who primarily speaks Mandarin, expressed concerns about call light response times and had to approach the nurse's station for attention. During a test of her call light, staff were unable to communicate effectively with her due to the language barrier. Resident #167's family member reported having to take their loved one to the bathroom after the call light went unanswered for over 45 minutes. A CNA reported being assigned 16 residents, some on different hallways, and stated there was no system to alert them to call lights on other hallways. The most recent Resident Council minutes and a grievance form also reflected concerns about call light response times.
Environmental Safety and Sanitation Deficiency
Penalty
Summary
The facility failed to provide a safe, functional, and sanitary environment for its census of 56 residents and staff. During an environmental tour, an accumulation of dust and debris was observed on the flooring of the [NAME] Hall's dietary storage closet. Additionally, two physical therapy cold compresses were found stored in the activity room's freezer, which was designated for food storage only. Lift batteries and charging stations were also observed being stored in the soiled utility rooms on both the first and second floors. When inquired, the Housekeeping Supervisor indicated that the lift batteries and charging stations had always been stored there but agreed to move them to a cleaner area.
Failure to Maintain Resident Dignity and Communication
Penalty
Summary
The facility failed to maintain the dignity of two residents, resulting in feelings of anger, frustration, and potential decreased self-worth. Resident #42, who is cognitively intact and requires partial assistance for ambulation and toileting, was observed attempting to communicate with a staff member in a different language. The staff member, unable to understand, asked the resident to speak English and then left without providing the needed assistance, leaving the resident's call light turned off. This interaction occurred despite the resident's clear need for help with toileting, as indicated by her response and body language. Resident #50, who is cognitively impaired and requires assistance with personal care, reported concerns about the response time to his call light. He stated that he often had to wait up to an hour for assistance and that his call light was sometimes out of reach. On one occasion, after dinner, he had to yell for help because his call light was not accessible. Despite hearing staff members in the hallway, his calls for help were met with a dismissive response and laughter, making him feel frustrated and worthless. These incidents highlight the facility's failure to respect and uphold the residents' dignity and communication needs.
Failure to Timely Repair Power Wheelchair
Penalty
Summary
The facility failed to provide timely repair services for a power wheelchair for a resident, resulting in dissatisfaction and reduced independence. The resident, who was cognitively intact and had a history of difficulty walking, shortness of breath, repeated falls, and paralytic gait, reported that the powerpack of her wheelchair stopped working in the fall. Despite notifying the social worker months ago, no follow-up was conducted to repair the wheelchair. The resident expressed a desire to have the wheelchair repaired to regain her mobility and independence, especially for outdoor activities with her family. The deficiency was further highlighted by the lack of communication and follow-up among the facility staff. The Therapy Director, who started in March, was unaware of the resident's need for a new battery, and the Social Worker had only recently been informed of the issue. The Director of Nursing acknowledged the delay in addressing the repair needs and indicated that the previous Therapy Director had failed to inform the staff about the required repairs. This lack of timely action and communication led to the resident's prolonged dissatisfaction and reduced mobility.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, resulting in potential inaccuracies in care plans and unmet care needs. Resident 5, a female admitted to the facility, was documented in the MDS as having adequate hearing and not using a hearing aid. However, observations and interviews revealed that Resident 5 had profound hearing loss and routinely used hearing aids, which she had difficulty using correctly. The social worker was unaware of Resident 5's hearing loss and the use of hearing aids, indicating a significant oversight in the resident's assessment and care planning. Resident 22, a female with borderline personality disorder and bipolar disorder, was incorrectly coded in the MDS as not having a serious mental illness according to the state Level II Pre-Admission Screening and Annual Resident Review (PASARR) process. However, the clinical record included two annual Level II OBRA assessments that determined Resident 22 had a severe mental illness. The social worker acknowledged the incorrect coding, highlighting a failure to accurately document the resident's mental health status, which could impact the appropriateness of her care plan.
Failure to Implement Comprehensive Care Plans and Address Language Barriers
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for a resident, resulting in unmet care needs and continued falls. The resident, who was cognitively intact but had multiple medical conditions including muscle weakness, orthostatic hypotension, and hemiplegia, required partial assistance for ambulation and toileting. Despite these needs, the care plan did not adequately address the resident's language barrier, which hindered effective communication and timely assistance. The resident primarily spoke Romanian, but the care plan incorrectly identified the language as Russian and failed to ensure the availability and use of translation services and communication tools. The resident experienced multiple falls, often while attempting to use the bathroom without assistance. Staff observations and interviews revealed that the resident's call light was frequently out of reach, and the resident was not consistently offered toileting every two hours as per the care plan. Additionally, interventions such as removing the bedside commode and encouraging the use of non-skid footwear were either not effectively implemented or failed to prevent further falls. The facility's documentation and post-fall evaluations did not adequately investigate the root causes of the falls, often attributing them to environmental factors or the resident's actions without addressing the underlying issues. Despite the resident's repeated falls and the family's expressed concerns about safety and care, the facility did not make necessary adjustments to the care plan or ensure consistent implementation of existing interventions. The lack of effective communication tools and translation services, combined with inadequate fall prevention measures, contributed to the resident's continued risk of falls and unmet care needs. Staff were often unsure about how to use translation services or locate communication tools, further exacerbating the resident's difficulties in receiving timely assistance.
Failure to Utilize Translation Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure communication services were available and appropriately utilized for a resident who primarily spoke Romanian. The resident, who had multiple medical conditions including hemiplegia and chronic glaucoma, was observed struggling to communicate her need to use the bathroom. Staff members were either unaware of or did not use the available translation services, leading to delays in addressing the resident's needs. The resident was found in distress multiple times, including instances where she had fallen and was unable to describe the events due to the language barrier. The resident's care plan indicated the need for translation services and communication tools, but these were not effectively implemented. Observations revealed that the communication board was not readily accessible and staff were unsure how to use the translation services. This lack of proper communication tools and training led to the resident being unable to communicate her needs effectively, resulting in falls and delayed assistance. Interviews with various staff members, including LPNs, CNAs, and the Director of Nursing, confirmed that the translation services were not consistently used. The resident's falls were documented, but the root cause was not adequately investigated due to the language barrier. The facility's failure to ensure effective communication contributed to the resident's repeated falls and unmet needs, highlighting a significant deficiency in care.
Failure to Ensure Appropriate Contracture Management
Penalty
Summary
The facility failed to ensure appropriate treatment and services for contracture management for a resident with multiple medical conditions, including chronic kidney disease, morbid obesity, and dementia. The resident, who had an amputation of the left leg above the knee and an acquired club foot, was observed lying in bed with her right foot in plantar flexion and her toes curled. She expressed that staff did not perform range of motion (ROM) exercises on her right foot and toes, which she wished they would do regularly. The medical record indicated a physician order for physical therapy evaluation and treatment, and the Point of Care (POC) documentation included tasks for daily maintenance of assisted active range of motion (AAROM) to all major joints. However, there was no documentation of completion or refusal of these tasks for the last 30 days. Interviews with staff revealed that the resident had refused ROM exercises in the past, leading the Certified Nursing Aide (CNA) to stop offering them. The Director of Nursing (DON) confirmed that ROM should be incorporated into daily care tasks and that staff are expected to perform ROM if indicated in the POC documentation. However, the DON could not explain the lack of documentation for the AAROM tasks and how staff should document refusals. This lack of documentation and follow-through on prescribed ROM exercises contributed to the deficiency in contracture management for the resident.
Failure to Prevent Falls and Address Communication Barriers
Penalty
Summary
The facility failed to prevent falls for a resident, resulting in recurrent falls and the potential for serious injury. The resident, who was admitted with multiple diagnoses including muscle weakness, orthostatic hypotension, and hemiplegia, experienced several falls despite having a care plan in place. The care plan included interventions such as encouraging the resident to wear non-skid footwear, ensuring the call light was within reach, and offering toileting every two hours. However, these interventions were not consistently followed or effective in preventing falls. On multiple occasions, the resident was found on the floor after attempting to use the bathroom without assistance. Staff observations and interviews revealed that the resident had a language barrier, speaking primarily Romanian, which hindered effective communication. Despite the availability of translation services and a communication board, these tools were not consistently utilized by the staff. The resident's call light was often found out of reach, and there were instances where the resident's requests for assistance were not promptly addressed. The facility's documentation showed repeated falls and post-fall evaluations, but the interventions implemented were either not new or not effective. For example, removing the bedside commode was listed as an intervention multiple times, and offering toileting every two hours was already an existing intervention. The facility's failure to address the root causes of the falls and ensure consistent use of communication tools contributed to the resident's recurrent falls and the potential for serious injury.
Failure to Administer Pain Medications as Ordered
Penalty
Summary
The facility failed to ensure that pain medications were administered as ordered for two residents, resulting in increased pain and potential unmanaged pain. Resident #45, a cognitively intact female with severe chronic pain and multiple diagnoses including cancer and a hip fracture, reported frequent delays in receiving her scheduled Morphine Sulfate ER. Observations confirmed that her medication was administered late on multiple occasions, and there was no evidence that the physician had been notified of these delays. The Director of Nursing confirmed that medications should be administered within one hour of the scheduled time and documented immediately, which was not done in this case. Resident #269, also cognitively intact, experienced severe pain and withdrawal symptoms due to delays in receiving her prescribed Fentanyl patch and Gabapentin. Despite the facility having these medications available in their pharmacy backup, the resident did not receive the Fentanyl patch until two days after it was due, and missed two doses of Gabapentin. Interviews with nursing staff revealed that the new admission process for residents with narcotic medications was not followed properly, and there was a lack of documentation explaining the delays. The Director of Nursing and other staff members acknowledged the deficiencies, stating that they would expect medications to be drop-shipped from the pharmacy within six hours and that any delays should be documented in the Electronic Medical Record. However, these expectations were not met, leading to unmanaged pain and withdrawal symptoms for the residents involved.
Failure to Ensure Proper Storage of Medications
Penalty
Summary
The facility failed to ensure proper storage of medications for two residents, resulting in the potential for unauthorized access to medications, medication errors, and adverse reactions. Resident #7 was observed with two inhalers on her bed, which she reported she had been keeping in her top drawer for about a year. The inhalers were later found in the bottom drawer of the medication cart, and the Licensed Practical Nurse (LPN) on duty was unaware of their removal. The Director of Nursing (DON) confirmed that medications should be stored in a lockbox and that an assessment for self-administration should be conducted, which had not been done for Resident #7. Additionally, Resident #42 was observed with two inhalers and three eye drop bottles on her windowsill. The LPN present believed that Resident #42 had a self-administration assessment, but this was not confirmed. The DON was unaware of Resident #42's medications and reiterated the requirement for a lockbox and an assessment for self-administration, which had not been completed for Resident #42 either.
Failure to Justify Antipsychotic Medication Use
Penalty
Summary
The facility failed to justify the use of an antipsychotic medication for Resident #5 (R5). R5 was admitted with diagnoses including visual hallucinations, adjustment disorder with depressed mood, and dementia. Despite a history of gradual dose reductions (GDR) for Quetiapine, the facility did not document adequate indications for the medication's use, nor did they attempt further GDRs as recommended by psychiatric services. The medical record lacked documentation of the negative impact of R5's hallucinations, other causes and medications considered, and individualized nonpharmacological interventions in place. R5's Quetiapine dosage was reduced multiple times but was increased back to 50 mg at bedtime after the patient and her daughter expressed concerns. The facility's documentation did not include any mention of hallucinations during this period. Subsequent notes from the physician and social services indicated that R5 experienced delusions and hallucinations, but these were not consistently documented or tracked in the medical record. The facility also failed to document the impact of these symptoms on R5 or any nonpharmacological interventions that were in place. Interviews with staff, including an LPN, CNA, and social workers, revealed inconsistencies in the documentation and monitoring of R5's hallucinations and delusions. The Director of Nursing (DON) acknowledged that the documentation was unclear and incomplete. Despite recommendations from psychiatric services to attempt further GDRs, the facility did not follow through, and the medical record did not provide adequate justification for the continued use of Quetiapine at the prescribed dosage.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
