Regency At Grand Blanc
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Blanc, Michigan.
- Location
- 1330 Grand Pointe Ct, Grand Blanc, Michigan 48439
- CMS Provider Number
- 235666
- Inspections on file
- 26
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Regency At Grand Blanc during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including recent hip fracture repair, DM, dementia, and cardiac history, expired in the facility, and nursing staff failed to document the event according to facility policy. The night-shift RN who initiated SQ hydration did not record a full assessment prior to CPR, did not document absence of pulse, BP, or respirations, and omitted the specific times CPR was started, EMS arrived, and resuscitation ended, noting only that the resident coded and was pronounced by EMS with family and provider notified. In a separate issue, another nurse later entered a sepsis screening with normal VS and no infection indicators for this same resident on a date after the resident’s death, without labeling it as a late entry or correcting it via strike-out or addendum, contrary to the facility’s documentation expectations policy.
Two residents with significant respiratory conditions did not receive safe and appropriate respiratory care when staff failed to perform and document thorough respiratory assessments and to maintain complete oxygen orders. One resident with acute respiratory failure and pneumonia had inconsistent and incomplete lung assessments despite low SpO2 readings, increased O2 needs, abnormal lung sounds, and ongoing antibiotic and nebulizer therapy; oxygen was restarted after desaturation without a new provider order, and documentation conflicted regarding infection status and respiratory findings. Another resident on continuous O2 via concentrator had an order that omitted the prescribed liter flow, leaving the oxygen therapy parameters incomplete despite diagnoses of acute respiratory failure with hypoxia, pneumonia, and end-stage disease.
Five residents' wheelchairs and motorized mobility devices were found to be visibly soiled, with packed substances, worn cushions, and debris, despite documentation indicating regular cleaning. Residents reported their wheelchairs were not cleaned regularly and could not recall the last cleaning, while the Environmental Services Director confirmed that cleaning was not consistently performed as required.
Multiple residents with respiratory conditions were found with nebulizer equipment containing residual fluid left at the bedside and oxygen tubing that was not labeled or dated as required. Staff confirmed that equipment was not cleaned, separated, or stored according to facility policy, and care plans for respiratory treatments were missing or incomplete.
Surveyors found unsanitary conditions in the kitchen, including a misaligned ice machine causing water pooling, dirty equipment such as a microwave and refrigerator, soiled cereal dispensers, and improper storage of clean items. The dish machine failed to consistently reach the required sanitizing temperature, with no documentation of corrective actions. Staff confirmed lapses in cleaning and maintenance, in violation of facility policy.
Multiple residents experienced a lack of dignity and respect when call lights were not accessible and staff response times were excessively long. One resident who is blind and at risk for falls could not locate his call light, which was found on the floor, while another resident requiring substantial toileting assistance was left unattended in the hallway and remained in soiled clothing due to delayed help. Family members also reported repeated issues with call light accessibility and long wait times for assistance.
A resident who was cognitively intact and made their own decisions was moved to a new room without being given advance written notice or an explanation for the change. The resident discovered their belongings had been moved after returning from therapy and expressed distress over not being informed. Staff contacted the resident's son instead of the resident, and no policy on room change notification was provided during the survey.
Two residents with severe cognitive and mobility impairments experienced multiple falls, including one resulting in a hip fracture, due to inadequate supervision and lack of effective fall prevention interventions. Care plans were not individualized or consistently implemented, residents were left unsupervised without call lights or activities, and incident documentation was incomplete, leading to preventable injuries.
Two residents did not receive timely changes to their medication regimens after pharmacy recommendations were accepted by practitioners. In one case, a resident continued to receive aspirin for months after it was recommended for discontinuation, and a dose reduction for famotidine was not implemented or documented. In another case, a resident's insulin regimen was not updated for two months after agreement to adjust, and the decision to maintain the current regimen was not documented. The facility's policy addressed review of recommendations but not the timeliness of implementing agreed-upon changes.
Two residents were found with medications stored at bedside without proper assessment for self-administration, and staff were unaware of the facility's policies regarding medication storage. One resident self-administered over-the-counter pain relief and hydrocortisone cream, while another had topical pain relief gel at bedside despite cognitive impairment and no assessment in place. Required policies and procedures were not provided during the survey.
Two residents developed new or worsening pressure ulcers due to the facility's failure to implement timely preventive measures, such as regular turning, repositioning, and skin assessments, and to update care plans with appropriate interventions. Delays in wound care and lack of preventive devices contributed to the deficiencies, despite both residents being at high risk for skin breakdown.
The facility did not promptly notify emergency contacts and physicians following significant changes in condition and incidents involving two residents with moderate cognitive impairment. In one case, a resident's family and physician were informed of a fall nearly ten hours after it occurred. In another, a resident's emergency contact was not notified of a hospital transfer and only discovered it during a visit. Staff interviews and documentation confirmed delays and lapses in required notifications.
A resident with multiple medical conditions and a history of falls developed a laceration on the left lower leg. Although a practitioner ordered the wound to be monitored due to the resident's use of a blood thinner, there was no documentation in the TAR of wound assessment, monitoring, or a care plan. Nursing notes referenced dressing changes but lacked detailed wound descriptions, and the discharge summary omitted the resident's skin condition and clear wound care instructions. The facility did not follow its own skin management policy for assessment, monitoring, and documentation.
A resident developed pressure wounds on both heels and buttocks due to inadequate interventions and lack of evaluation for effectiveness. Despite being at risk, the resident's care plan was not effectively implemented, with inconsistencies in repositioning and use of heel boots. The facility's documentation and staff interviews revealed conflicting reports about the resident's compliance with interventions, leading to the development and worsening of pressure wounds.
A facility failed to honor a resident's right to self-determination by not accommodating her dietary preferences, despite her expressed wishes and involvement of her family in medical decisions. The resident, with a history of dysphagia, was kept on an NPO status based on a previous failed swallow study, without being given the opportunity to make an informed decision about her dietary intake. The facility's policies on resident rights were not upheld, leading to a deficiency in honoring the resident's rights.
A resident with pressure ulcers and moderate malnutrition did not receive proper care as outlined in their care plan. Observations showed the resident lacked a pressure reduction cushion in their wheelchair and did not have their heels elevated or protected while in bed. The care plan was not linked to the Kardex, leading to CNAs not having the necessary information to provide appropriate care.
A facility failed to maintain a carpet in a resident's room, resulting in a persistent urine odor. Despite frequent shampooing, the odor remained, affecting air quality. The issue was reported by family members, but no grievance forms were completed. The maintenance director was unaware of prior complaints until reviewing logs. Plans to remove the carpet were confirmed by the nursing home administrator.
A resident at risk of aspiration pneumonia received tube feeding at an incorrect rate of 130 ml/hr instead of the ordered 65 ml/hr, leading to emesis and potential fluid overload. The error was discovered by a family member, and the resident was transferred to the hospital. The LPN responsible did not verify the feeding rate against the physician's order.
Incomplete and Inaccurate Clinical Documentation at Time of Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and timely clinical documentation for a resident who was admitted with multiple serious medical conditions and later expired at the facility. The resident had a history of a recent hip fracture with surgical repair, Diabetes Mellitus, Dementia, Anxiety Disorder, coronary angioplasty with stents, and malignant neoplasm of the eye, among other diagnoses. A Medical Examiner’s report determined the death to be from natural causes and ruled out foul play. On the night of the resident’s death, Nurse A worked the 11:00 PM to 7:30 AM shift and had initiated subcutaneous hydration before her shift. She reported that the 3–11 nurse had told her the resident had shallow breathing and appeared pale. The nursing assistant confirmed the resident was still breathing at around 1:00 AM, and at approximately 2:30 AM the resident was found unresponsive, a code was overhead paged, and CPR was started. Nurse A acknowledged that she did not follow standards of nursing documentation: she failed to document the assessment findings prior to CPR (such as absence of pulse, blood pressure, and respirations), the time CPR was started, the time EMS arrived and took over, and when resuscitation was stopped. Her only progress note entry at 3:16 AM stated that the resident coded at approximately 2:30, that 911 was alerted, the resident was pronounced at 2:44 AM by EMS, and that the provider group and daughter were notified, without the detailed assessment and pronouncement information required by the facility’s “Death of a Resident” and “Documentation Expectations” policies. A separate documentation issue was identified with Nurse B, who completed a Sepsis Screening Evaluation in the electronic record for this resident on a date after the resident had already been deceased for several days, with no indication that the entry was a late entry or an error. The sepsis screen documented normal vital signs, no suspected infection, and no antibiotic therapy, and was electronically signed on that later date without any strike-out or late-entry notation. In interview, Nurse B stated she was unaware she had documented an assessment on the resident after death, reported she did not have access to the strike-out function, and suggested it might have been for another patient or a late entry with an incorrect date, but she could not recall the specifics. The DON confirmed that the resident had passed away before the date of Nurse B’s documented assessment and stated they were not sure what happened with that entry. These actions and omissions conflicted with the facility’s policies requiring contemporaneous, accurate documentation, proper correction of errors via strike-out or addendum, and clear identification of late entries.
Failure to Perform Thorough Respiratory Assessments and Maintain Complete Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care by not completing thorough respiratory assessments and not maintaining complete oxygen orders for two residents. One resident was admitted with multiple diagnoses including acute respiratory failure and later developed pneumonia, with radiology showing right upper lobe infiltrate and subsequent worsening bilateral opacities concerning for pneumonia. Nursing progress notes documented intermittent cough, shortness of breath (SOB), and use of supplemental O2, but lung assessments were inconsistently documented and often lacked detailed respiratory findings such as lung sounds. Although the resident’s oxygen was discontinued after initial improvement, when oxygen saturations later dropped into the low 80s on room air, oxygen therapy was restarted without a corresponding new physician order being entered into the medical record. During the period when the resident had pneumonia twice, documentation showed minimal thorough respiratory assessments despite ongoing respiratory symptoms and treatment with antibiotics, inhalers, and nebulizer treatments. Notes indicated low SpO2 readings, increased O2 requirements, and abnormal lung findings such as diminished sounds and wheezing, but the chart lacked consistent, detailed lung assessments across shifts. A skilled care note on one day listed the resident’s respiratory status as “None,” and a sepsis screening completed almost simultaneously indicated no documented infection or antibiotic therapy, which conflicted with the resident’s active pneumonia diagnosis and antibiotic treatment. A nurse working an evening shift reported that she did not assess lung sounds at any time during her shift, including before or after administering a breathing treatment, despite having been told in report that the resident “did not sound too good.” The sequence of events leading up to the resident’s transfer to the hospital included rising oxygen needs, low oxygen saturations despite increased O2 flow, and abnormal lung sounds described by night-shift staff, but the timing and progression of the change in condition could not be clearly determined from the record due to inconsistent and incomplete respiratory documentation. The Infection Preventionist acknowledged that charting during this period was inconsistent and did not provide an accurate depiction of the resident’s respiratory status, and agreed that lung sounds would have been abnormal given the pneumonia diagnosis. Hospital records later documented that the resident had needed more oxygen than her baseline and was admitted with extensive bilateral pneumonia, acute-on-chronic respiratory failure, and other complications, ultimately leading to death. A second resident was observed using supplemental oxygen via concentrator, with the device set at 2 L, but the corresponding physician order only stated to provide O2 via nasal cannula to maintain SpO2 greater than 89% and did not specify the liter flow or range. The unit manager confirmed that the liter amount was not listed in the order. This omission meant that the oxygen order for this resident was incomplete, as it lacked a defined flow rate despite the resident having diagnoses including acute respiratory failure with hypoxia, pneumonia, and end-stage disease.
Failure to Maintain Clean and Sanitary Wheelchairs for Multiple Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for five residents by not ensuring their wheelchairs and motorized mobility devices were regularly cleaned, sanitized, and free from damage. During a Resident Council meeting, multiple residents reported that their wheelchairs were not cleaned on a regular basis and could not recall the last time cleaning occurred. Observations revealed that the wheelchairs had packed substances in crevices, worn cushions, dried-on substances, and visible dust and debris. Documentation indicated that cleaning was supposed to occur weekly, but the observed condition of the wheelchairs did not align with these records. Further interviews and observations with the Environmental Services Director confirmed that staff typically inspect and clean wheelchairs monthly, which contradicted the documented weekly cleaning schedule. Specific examples included wheelchairs with ripped seat cushions, thick buildup of substances, and crusted-on debris. Residents consistently reported not recalling when their wheelchairs were last cleaned, and the Environmental Services Director acknowledged that regular cleaning was not being addressed as required.
Failure to Ensure Proper Respiratory Equipment Care and Labeling
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for multiple residents by not ensuring proper storage, cleaning, and labeling of respiratory equipment. Observations revealed that several residents had nebulizer masks or medication chambers with visible fluid left in them after use, and the equipment was not properly cleaned, separated, or stored as per facility policy. In one case, a resident's nebulizer mask was left on the dresser with fluid in the medication cup, and there was no care plan or intervention documented for nebulizer use. Other residents were found with nebulizer equipment containing fluid days after their last treatment, and staff confirmed that the equipment should have been cleaned and stored appropriately but was not. Additionally, a resident receiving oxygen therapy had tubing that was not labeled or dated as required by facility policy, and staff acknowledged that labeling should have occurred upon admission but did not. The residents involved had various diagnoses including COPD, asthma, respiratory failure, heart failure, and mental health conditions. At the time of the deficiencies, some residents were no longer receiving nebulizer treatments, yet equipment with residual medication was still present at the bedside. Staff interviews confirmed that the observed practices did not align with facility policies, which require cleaning, drying, and proper storage of nebulizer equipment, as well as labeling and dating of oxygen tubing. The lack of adherence to these procedures was directly observed and verified by nursing management.
Deficient Sanitation and Equipment Maintenance in Food Service Area
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations, specifically related to the maintenance and sanitation of kitchen equipment and the environment. During a kitchen tour, several unsanitary conditions were observed, including a puddle of water behind the ice machine, a drain grate with dark orange/brown discoloration, and tubing covered in visible brown dust. The microwave had food splatters inside, and the cook's refrigerator contained dried food particles and smudges both inside and outside the door. The cereal dispenser chutes had a film of debris, and the tray line refrigerator had a loose door seal and ice/frost buildup. Additionally, the drain/grate under the sink was soiled, ready-to-use cups were stored against a soiled step stool, and baking sheets were found wet. The walk-in freezer also had ice/frost buildup on the fan blades. Dishwashing practices were also found to be deficient. The dish machine required eight racks to reach the required final rinse temperature of 180°F, and review of temperature logs showed multiple days where the rinse temperature was below the minimum standard, with no documentation of corrective actions taken. Staff interviews confirmed that the ice machine was not properly aligned with the drain, causing water to pool, and that certain cleaning tasks, such as cleaning the drain covers, had not been performed by environmental services staff. The facility's policy required proper cleaning and sanitizing of food service equipment, but these standards were not met as evidenced by the observations and record review.
Failure to Ensure Call Light Accessibility and Timely Response Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure resident dignity and safety by not making call lights accessible, resulting in extended response times and lack of respectful treatment for multiple residents. One resident, who is blind and has a history of falls and moderate cognitive impairment, reported difficulty locating his call light, often having to feel around his bed to find it. During observation, his call light was found on the floor under the bed, and staff acknowledged that it was not placed within his reach as required by his care plan. Another resident, who is cognitively intact and requires substantial assistance with toileting, reported being left alone in the hallway for an extended period after lunch without access to a call light. She experienced incontinence and remained in soiled clothing for a prolonged time. Her son confirmed that the call light was often found on the floor and that response times to her requests for assistance were excessively long, sometimes up to two hours. The resident's care plan specified the need for frequent checks and prompt toileting assistance, which was not followed.
Failure to Provide Advance Written Notice and Obtain Consent for Room Change
Penalty
Summary
A cognitively intact resident who was capable of making their own medical and financial decisions was moved to a different room without being provided advanced written notification or the rationale for the change. The resident reported returning from therapy to find all personal belongings had been moved, and expressed anger and confusion about not being informed beforehand. Certified Nursing Assistants confirmed the resident was upset and did not understand why the move occurred, and no staff could provide an explanation at the time. Review of the resident's records showed that the Notice of Room Change assessment form indicated only the resident's son was contacted, despite the resident being their own responsible party. The form was signed by social services staff after the move had already occurred. During interviews, social services staff admitted to routinely contacting next of kin rather than the resident, and acknowledged not notifying the resident prior to the move. The facility was unable to provide a policy or procedure related to notification of room changes by the end of the survey.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of meaningful interventions to prevent falls for two residents with severe cognitive impairment and significant mobility deficits. One resident, who was under hospice care with multiple diagnoses including congestive heart failure, diabetes with neuropathy, vascular dementia, and end-stage renal disease, required substantial assistance for mobility and transfers and had visual impairment. Despite these needs, the resident's care plan did not address safety and monitoring after dialysis or when left unsupervised in a chair. The resident experienced an unwitnessed fall after returning from dialysis, with the wheelchair brakes found unlocked and no documentation of supervision, call light accessibility, or recent toileting. Staff interviews revealed uncertainty about the resident's supervision and lack of clear interventions to prevent falls after dialysis. Another resident with a history of falls, severe cognitive impairment, and substantial assistance needs for transfers and mobility experienced multiple falls, including one resulting in a hip fracture. The care plan included general fall prevention interventions, but documentation and staff interviews indicated that these were not consistently or effectively implemented. The resident was frequently left unsupervised near the nurses' station without activities or a call light, and staff were not always present or able to observe the resident. Incident and accident forms lacked critical details such as last toileting, footwear, continence status, and staff presence at the time of falls. Post-fall evaluations and investigations were incomplete, with discrepancies in documentation and unclear root causes for the falls. Staff interviews and record reviews highlighted gaps in supervision, incomplete investigations, and insufficient communication regarding interventions and staff assignments. The facility did not provide adequate documentation of staff presence or actions taken at the time of the incidents, and there was a lack of meaningful, individualized interventions following repeated falls. The failure to provide adequate supervision and implement effective fall prevention strategies resulted in preventable injuries, including a hip fracture, for residents at high risk due to cognitive and physical impairments.
Delayed Response to Pharmacy Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to timely respond to pharmacy recommendations for two residents regarding unnecessary medications, as identified through observation, interview, and record review. For one resident with chronic respiratory failure, major depressive disorder, adjustment disorder, anxiety, and GERD, the pharmacist recommended reevaluating the use of both Eliquis and low-dose aspirin due to her low hemoglobin, and the practitioner agreed to discuss and adjust the treatment. However, there was a delay in discontinuing aspirin, and after a hospital readmission, aspirin was restarted and continued for several months before being discontinued again. Additionally, the pharmacist recommended reducing the dose of famotidine due to potential adverse effects, but the practitioner disagreed, citing a previous unsuccessful gradual dose reduction, which was later confirmed by the DON to have not been completed or documented. For another resident with diabetes, anxiety disorder, chronic kidney disease, hypertension, bipolar disorder, and dementia, the pharmacist recommended increasing the Humalog dose and discontinuing sliding scale insulin, as prolonged use of sliding scale insulin is not recommended. The practitioner agreed to discuss and adjust the insulin regimen, but the order was not updated for two months. Documentation did not reflect the intended changes, and the practitioner later stated that after discussing with the resident, it was decided to maintain the current insulin regimen, but this was not documented in the progress notes or medication review. The facility's policy required practitioners to review and sign off on pharmacist recommendations within 14 days but did not address the timeliness of implementing agreed-upon changes. In both cases, there was either a delay or lack of documentation in acting upon pharmacy recommendations that were accepted by practitioners, resulting in continued administration of medications that were recommended for change or discontinuation.
Failure to Ensure Safe Bedside Medication Storage and Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional principles, specifically regarding bedside medication storage and self-administration assessments. For one resident with diagnoses including bipolar disorder, depression, anxiety, and a colostomy, over-the-counter migraine pain relief and hydrocortisone cream were found on the overbed table. The resident reported self-administering these medications for pain and a rash, and stated that the medications had been kept at bedside for several months without staff intervention. The acting DON confirmed that a self-administration assessment and provision of a lock box should have been completed, but these steps were not taken. Another resident with heart disease, arthritis, and a history of falls, who was moderately cognitively impaired, was observed with Biofreeze (a topical pain relief gel) and individual packets of the same medication on their overbed table. The acting DON acknowledged that Biofreeze is considered a medication and that the resident was not permitted to self-administer medications. There was no care plan or assessment in place for self-administration for this resident. Additionally, the facility failed to provide requested policies and procedures related to medication storage and self-administration by the conclusion of the survey.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide services to prevent the development of new pressure ulcers and did not implement appropriate skin care interventions for two residents with pressure ulcers. One resident, who was admitted with multiple diagnoses including spinal stenosis, recent spinal fusion, and diabetes, was dependent on staff for most activities of daily living and was at risk for pressure ulcers. Despite being identified as at risk, there was no evidence of preventive measures such as turning, repositioning, or frequent skin assessments upon admission. The resident developed new pressure wounds on the buttocks, which were not identified until several days after admission, and preventive interventions were only implemented after the wounds were discovered. Another resident, admitted with diabetes, acute kidney failure, cellulitis, and neuromuscular dysfunction of the bladder, also experienced inadequate wound care. This resident had a history of wounds on the lower extremities and developed additional pressure wounds on the buttocks and a new wound on the right big toe during their stay. The care plan for this resident was not updated with new interventions after the discovery of new wounds, and there was a delay in dressing changes and implementation of preventive devices, despite requests from the resident's family. The facility's own skin management policy requires identification and implementation of preventive measures for residents at risk of pressure injuries, as well as timely documentation and care planning. In both cases, the facility did not follow these protocols, resulting in the development and worsening of pressure ulcers, and a lack of timely and appropriate interventions to promote healing and prevent further skin breakdown.
Failure to Timely Notify Emergency Contacts and Physicians of Resident Incidents
Penalty
Summary
The facility failed to immediately notify the emergency contact and physician regarding significant changes in condition and incidents affecting two residents. In one case, a resident with moderate cognitive impairment and a history of falls experienced an unwitnessed fall in the early morning. Documentation showed that the physician and family were not notified until approximately ten hours after the incident, despite the resident being found confused and requiring treatment for an aggravated area on the leg. The nurse's notes included late entries, and the author was not identified, limiting the ability to verify the accuracy of the documentation and the timeliness of notifications. In another instance, a resident with moderate cognitive impairment and multiple medical diagnoses, including heart failure and a history of falls, experienced a significant change in mental status and was transferred to the hospital. The resident's emergency contact, her son, was not notified of the hospital transfer and only learned of it upon visiting the facility. Staff interviews confirmed that the responsible nurse did not notify the emergency contact, and the nurse practitioner did not make the notification either, as it was not her responsibility. These failures to promptly notify emergency contacts and physicians of changes in condition, falls, and hospital transfers were identified during the survey. The lack of timely communication was confirmed through record reviews, incident reports, and staff and family interviews, demonstrating a deficiency in the facility's adherence to notification requirements.
Failure to Assess, Monitor, and Document Wound Care After Resident Fall
Penalty
Summary
A resident with multiple complex medical diagnoses, including dysphagia, malignant neoplasm of the lung, and hemiplegia, experienced several falls during their stay. Following a fall, the resident sustained a laceration on the left lower leg. The nurse practitioner assessed the wound and ordered it to be left open to air and monitored for bleeding, given the resident's use of a blood thinner (Apixaban), which increased the risk of bleeding. Despite these orders, there was no documentation in the Treatment Administration Record (TAR) of any assessment, monitoring, or specific treatment orders for the left lower leg wound. Additionally, no care plan was established to address the wound or its monitoring needs. Nursing progress notes indicated that the resident aggravated the left lower leg wound by rubbing at night, and a dressing was applied to prevent further injury. However, the TAR did not reflect any daily or frequent monitoring of the wound as recommended. Subsequent nursing notes referenced the application of a xeroform dressing but lacked detailed documentation regarding the wound's characteristics, such as size, depth, or presence of swelling, discoloration, or discharge. There was also a lack of consistent and thorough documentation of the wound's status and any changes over time. Upon discharge, the post-discharge summary failed to document the resident's skin condition at the time of discharge and did not provide clear instructions for ongoing wound care. The facility's own skin management policy requires identification, evaluation, and appropriate treatment of wounds, as well as ongoing monitoring and documentation, none of which were consistently followed in this case. The lack of proper assessment, monitoring, documentation, and care planning for the resident's wound constituted a failure to provide appropriate treatment and care according to orders and the resident's needs.
Inadequate Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide adequate and appropriate interventions to prevent the development and healing of pressure wounds for a resident, resulting in the resident developing pressure wounds on both heels and buttocks. Upon admission, the resident was at risk for pressure ulcers but did not have any unhealed pressure ulcers. The resident's medical record indicated a decline in condition, including poor oral intake, decreased mobility, and a preference to remain in bed, which contributed to the development of pressure wounds. The resident's care plan included interventions such as encouraging out-of-bed activity, side-lying positioning, and the use of soft boots or pillows to elevate heels. However, there was a lack of evaluation for the effectiveness of these interventions, and they were not revised to address the resident's non-compliance. Interviews with family members and staff revealed inconsistencies in repositioning practices and the use of heel boots, with the resident often found lying on their back without the prescribed interventions in place. The facility's documentation and interviews with staff indicated that the resident did not exhibit behaviors of care refusal, yet there were conflicting reports about the resident's compliance with repositioning and other interventions. The facility's policies on skin management and nursing practice emphasize the importance of evaluating and updating care plans, but these were not effectively implemented for the resident, leading to the development and worsening of pressure wounds.
Facility Fails to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not accommodating her dietary preferences, despite her expressed wishes and involvement of her family in medical decisions. The resident, a 77-year-old female with a history of dysphagia and other medical conditions, was admitted to the facility with a PEG tube for nutrition due to her inability to safely swallow liquids and solids. Despite her desire to eat food orally, the facility staff adhered strictly to the NPO (nothing by mouth) order based on a previous failed swallow study, without offering the resident the opportunity to make an informed decision about her dietary intake. The resident's sister, who held medical power of attorney, was actively involved in her care and had requested a second opinion from an ENT specialist. The ENT recommended further swallow evaluations, but the facility did not initially accommodate the resident's request for oral intake, citing safety concerns. The resident expressed sadness and frustration over being denied food by mouth, which she had requested multiple times since her admission. The facility's speech therapist and medical director decided to discharge the resident from speech therapy, maintaining the NPO status without considering the resident's right to make informed choices about her care. The facility's policies on resident rights, including the right to refuse treatment and make choices about their care, were not upheld in this case. The resident's advanced directive and the involvement of her family in decision-making were not adequately considered, leading to a deficiency in honoring the resident's rights. The facility's failure to provide the resident with the opportunity to make informed decisions about her dietary preferences, despite her cognitive ability to understand the risks, resulted in a violation of her rights to self-determination and choice.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was admitted with moderate protein-calorie malnutrition and had pressure ulcers on their coccyx and left heel. The resident was observed in a high back wheelchair without a pressure reduction cushion, which was supposed to be in place according to their care plan. The cushion was found on the bed instead of the wheelchair, and the resident reported significant pain from their wounds. Additionally, the Kardex, which guides CNA care, did not mention the need for a wheelchair cushion or dycem, leading to a lack of proper implementation of the care plan. Further observations revealed that the resident's heels were not elevated while in bed, and protective boots were not used as required. The Kardex indicated that the resident's heels should be floated on a pillow or protected with heel protectors, but this was not followed. A CNA was observed providing care alone, contrary to the care plan that required two-person assistance for bed mobility. The Unit Manager confirmed the discrepancies, noting that the care plan was not linked to the Kardex, which contributed to the CNAs not having the necessary information to provide appropriate care.
Persistent Urine Odor Due to Ineffective Carpet Maintenance
Penalty
Summary
The facility failed to effectively clean and maintain the carpet in a specific room, leading to a persistent and strong odor of urine. This issue was initially reported by a family member who noted the odor when their loved one was admitted to the room. Despite the resident being moved, the odor persisted, affecting the current occupant. Housekeeping staff confirmed the difficulty in removing odors from old carpets, even with frequent shampooing. The maintenance director was unaware of prior complaints until reviewing the maintenance work log, which showed multiple reports of the odor issue. The maintenance director acknowledged the lack of a follow-up system to ensure the issue was resolved, as the only action taken was to shampoo the carpet, which did not eliminate the odor. The facility's maintenance records indicated that the odor was reported by different families on separate occasions, but no grievance forms were completed. The nursing home administrator confirmed plans to remove the carpet from the affected room, although the facility was unable to replace all carpets at once. The persistent odor was noted during multiple observations, and the air quality in the room was affected, with a humid and chemical smell present.
Failure to Administer Tube Feeding at Correct Rate
Penalty
Summary
The facility failed to ensure that a resident, who was at risk of aspiration pneumonia, received tube feeding according to the physician's order. The resident, who had a history of extradural and subdural abscess, sepsis, morbid obesity, dysphagia, weakness, reduced mobility, and a history of COVID-19 with respiratory failure, was supposed to receive tube feeding at a rate of 65 ml/hr. However, the feeding was administered at a doubled rate of 130 ml/hr, leading to an episode of emesis and the potential for fluid overload. This error was discovered by a family member, who found the feeding rate set incorrectly and insisted on transferring the resident to the hospital for evaluation. The incident occurred when Nurse LPN C, who was responsible for administering the tube feeding, did not verify the rate of the feeding pump against the physician's order. The nurse admitted to not checking the rate when hanging a new bag of feeding, which may have been pre-programmed incorrectly. The facility's records and interviews confirmed that the nurse did not follow the proper procedure of verifying the rate and volume with every dose, as emphasized in a subsequent nurses' meeting. The resident was found supine with clinical indicators of aspiration pneumonia, which was confirmed by hospital records.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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