Regency At Whitmore Lake
Inspection history, citations, penalties and survey trends for this long-term care facility in Whitmore Lake, Michigan.
- Location
- 8633 N Main Street, Whitmore Lake, Michigan 48189
- CMS Provider Number
- 235545
- Inspections on file
- 35
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Regency At Whitmore Lake during CMS and state inspections, most recent first.
A resident who was dependent on staff for bed mobility received catheter and peri care from a CNA using only a one-person assist, contrary to the care plan and Kardex instructions requiring two-person assistance. The CNA rolled the resident away from herself and left the resident close to the edge of the bed without handrails, increasing the risk of falling. The DON confirmed that the care plan required two-person assistance and proper technique, but the CNA had not reviewed the care plan recently.
The facility did not complete the care plan within 7 days of the comprehensive assessment and did not ensure that a team of health professionals prepared, reviewed, and revised the care plan as required.
The facility did not maintain room temperatures within the required 71-81°F range, with multiple areas exceeding this limit. Staff and a resident reported issues with inadequate cooling, old HVAC systems, and portable air conditioners that sometimes tripped circuit breakers. Despite weekly monitoring and use of fans and portable units, surveyors found several rooms and common areas above the regulatory temperature range.
Surveyors found that multiple residents received meals that were often cold, dry, repetitive, and lacking in condiments, with food preferences not consistently honored. Food trays were sometimes left in insulated carts for extended periods, resulting in improper temperatures, and staff did not always follow procedures for tray accuracy. Palatability tests and resident interviews confirmed issues with meal quality, presentation, and portion sizes, affecting residents' willingness to eat and potentially impacting their nutrition.
A resident experienced a delay in receiving their lunch meal, with the tray observed stored in a hallway cart past the usual serving time and not delivered until later by a CNA. This delay was inconsistent with the facility's stated meal service policy and affected up to 116 residents, increasing the likelihood of distress and decreased nutritional intake.
A deficiency was cited due to egress doors being equipped with locks or latches that require a tool or key from the egress side, without meeting the required special locking arrangement standards. The facility did not ensure that all conditions for clinical, security, or special needs locking—such as fail-safe electrical locks and integration with fire protection systems—were met, as observed during the survey.
A deficiency was cited due to corridor doors and doors protecting corridor openings not meeting regulatory requirements for fire and smoke resistance, positive latching hardware, and proper door clearance, as observed during the survey.
A resident with Alzheimer's disease and severe mental impairment was involved in multiple incidents of inappropriate sexual behavior toward female residents. Despite staff attempts to supervise, there was no formal care plan or consistent documentation of one-on-one supervision until after repeated incidents. Staff interviews revealed confusion about supervision requirements, and assignment sheets did not indicate the need for one-on-one monitoring.
A resident with severe cognitive impairment and a history of inappropriate sexual behavior was not consistently provided with one-on-one supervision, despite staff awareness of the need. Staff interviews and documentation review revealed that the supervision plan was not formalized as a physician's order, and assignment sheets did not indicate one-on-one supervision. This lack of clear communication and documentation resulted in repeated incidents where the resident was found unsupervised and engaging in inappropriate behavior with other residents.
The facility failed to prevent and correctly identify pressure ulcers for two residents, leading to misidentification and worsening of their conditions. One resident had a stage III pressure ulcer on the buttock, with incomplete skin assessments and care plans. Another resident had a painful pressure ulcer on the foot and a sacral wound misidentified as unstageable. The facility's interventions were not fully implemented, and staff lacked awareness of the residents' wound conditions.
A facility failed to provide palatable and appropriately temperature-controlled food, affecting 119 residents. Observations showed food items were often served below FDA temperature standards, leading to dissatisfaction. Residents reported meals were cold, unappetizing, and repetitive. Despite temperature audits, issues persisted, indicating inadequate resolution of the problem.
The facility failed to maintain and clean food service equipment, affecting 119 residents and increasing the risk of cross-contamination. Observations revealed soiled can opener assemblies and improperly stored scoops in food bins. Additionally, a loose ventilation grill in the dry storage room was noted. The facility's policies on maintenance and sanitation were not effectively implemented, leading to these deficiencies.
The facility did not reassess its ability to meet resident care needs after changes in resident acuity, including pressure ulcers, falls, and catheter care requirements. The assessment incorrectly listed the Administrator as the Governing Body, and the Administrator was unaware of her accountability to the actual Governing Body.
The facility failed to maintain a clean and safe environment, affecting 119 residents. Observations revealed issues such as a damaged smoking area canopy, porous surfaces in the laundry service area, and multiple maintenance deficiencies throughout the facility, including leaking water valves, broken light covers, and missing atmospheric vacuum breakers in shower rooms. The facility's maintenance policies were not effectively implemented, as evidenced by the lack of specific entries in the work order system for the observed concerns.
A resident with dementia reported abuse by a CNA, but the facility failed to report the allegation to the State Agency. Despite the resident's confusion and inability to identify the perpetrator, the facility's policy requires reporting all abuse allegations, substantiated or not, within specified timeframes. The NHA and SW concluded the abuse was unsubstantiated and did not report it, contrary to policy.
The facility failed to develop and implement comprehensive care plans for two residents with pressure ulcers. One resident had a stage III ulcer and moisture-associated skin damage, with care plan deficiencies in addressing refusals and interventions. Another resident, on hospice care, had pressure ulcers deemed unavoidable, but the care plan lacked interventions for refusals and coordination with hospice. Staff interviews revealed inadequate root cause analysis and documentation, highlighting systemic issues in wound care management.
A facility failed to revise the care plan for a resident with hand and muscle contractures. Despite recommendations for the resident to wear hand and elbow splints, observations showed the splints were not used, and staff interviews revealed inconsistencies in offering the splints. The care plan was not updated following therapy recommendations, leading to a deficiency in care.
A resident with dementia did not receive necessary podiatry care despite multiple requests from a family member over five months. The family member struggled to manage the resident's toenail care due to the nails' thickness and curling. Facility staff interviews revealed a lack of communication and responsibility in arranging podiatry services, with the LPN/Unit Manager acknowledging that the condition should have been documented and addressed during routine assessments.
A resident with hand contractures did not receive prescribed hand splints and positioning wedge to maintain range of motion. Despite care plans indicating the need for these interventions, observations showed the splints were not in use, and the resident reported being left on his back without repositioning. Staff interviews revealed inconsistencies in offering and applying the splints, and the care plan lacked updates following therapy recommendations.
A facility failed to ensure a physician documented the review of medication irregularities for a resident with cognitive impairment. The resident was on Divalproex and experienced mental status changes. The pharmacist recommended monitoring certain levels due to potential adverse effects, but there was no documentation of the physician's response. The DON could not find any documentation or explanation for the lack of physician action.
The facility failed to meet the nutritional needs and preferences of two residents, leading to dissatisfaction with meal consistency and adherence to dietary restrictions. One resident reported inconsistencies in receiving a chef salad and received meals with unwanted barbecue sauce. Another resident, who is underweight, experienced cold meals and missing items from their meal ticket. The Dietary Manager acknowledged issues with food availability and preparation, contributing to these deficiencies.
The facility failed to address pressure ulcers through its QAPI committee, resulting in two residents developing stage III or higher pressure ulcers. The wound nurse did not perform root cause analyses, and the DON did not conduct audits or implement plans to prevent further ulcers. The Administrator acknowledged the lack of a performance improvement plan for pressure ulcers.
A resident's social security debit card was misappropriated by an Activities Aide (AA) who was later arrested and charged with felonies for unauthorized use. The resident, with intact cognition, reported the AA as the last known person to have the card. Unauthorized transactions occurred while the resident was hospitalized, leading to the AA's identification through video footage and transaction records. The incident resulted in the resident's brother managing the card, causing a delay in personal purchases.
A resident with severe cognitive impairment was inappropriately restrained in a long-term care facility. Staff used a foam wedge to prevent the resident from leaving the bed and frequently placed him in a geri-chair, restricting his mobility. The resident, who was active and able to propel himself in a manual wheelchair, was often immobilized for convenience. The Director of Nursing acknowledged the misuse of restraints, which were not medically necessary.
A resident with severe cognitive impairment and a history of falls experienced a delay in receiving a stat x-ray for a hip and femur fracture. Despite staff awareness of the resident's condition and attempts to contact radiology, the x-ray was not completed before the resident was transferred to the hospital. The hospital confirmed fractures requiring surgery. The facility's DON acknowledged the delay and the need for supervision during the resident's unwitnessed fall.
A resident with severe cognitive impairment and a history of falls experienced a major injury due to inadequate fall prevention measures and delayed medical imaging. The resident, who was mobile and able to self-propel in a wheelchair, was often placed in a restrictive geri-chair, leading to restlessness and attempts to exit. Staff were unaware of the purpose of a foam wedge used to prevent the resident from exiting the bed, and there was a significant delay in obtaining a stat x-ray after the resident's family reported swelling and bruising.
A resident with a history of medical conditions experienced a fall and fracture due to inadequate supervision and failure to follow care-planned interventions. The resident was not properly positioned in a shower chair and was left unattended, leading to a fall. The incident was not reported immediately, and the care plan requiring a Hoyer lift was not followed, resulting in increased pain and medication needs for the resident.
A resident with Alzheimer's Disease experienced repeated falls due to inadequate supervision and engagement from staff in a locked unit. Despite the presence of CNAs and an RN, there was a lack of interaction with residents, leading to multiple falls. The facility's interventions, such as medication adjustments and diversional activities, were inconsistently implemented, and there was no thorough analysis of the falls' root causes.
A facility failed to provide adequate supervision and care on a unit for residents with cognitive impairments. A nurse took an extended break without ensuring coverage, leaving only an activities aide with the residents. This resulted in residents being unassisted, with some attempting to leave the unit or access restricted areas. The facility's protocol for staff breaks and coverage was not followed, leading to a deficiency in maintaining professional standards of care.
A facility failed to monitor and document a resident's blood pressure before administering amlodipine, as required by the physician's order. The resident, with severely impaired cognition and hypertension, had no recorded blood pressures in May and June 2024, despite receiving the medication daily. The DON confirmed the lack of documentation and improper order entry, violating the facility's medication administration policy.
Failure to Provide Two-Person Assist for Bed Mobility as Directed by Care Plan
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) provided activities of daily living (ADL) care to a resident who was dependent on staff for bed mobility, as documented in the resident's care plan and Kardex. The care plan specified that the resident required the assistance of two staff members for all bed mobility tasks, including rolling side to side. However, during an observation, the CNA performed catheter and peri care with only a one-person assist, instructing the resident to roll independently and rolling the resident away from herself rather than towards herself. The resident was observed to be very close to the edge of the bed during this process, and there were no handrails present to prevent a fall. Further review of the resident's records confirmed the requirement for two-person assistance with bed mobility. In interviews, the CNA stated she believed the resident was a one-person assist and had last reviewed the care plan three days prior. The Director of Nursing (DON) confirmed that the care plan required two-person assistance and that staff should roll residents towards themselves, not away. The failure to follow the established care plan and facility protocols for bed mobility assistance led to the deficiency.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. Additionally, the care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the surveyor's review of facility practices and documentation.
Failure to Maintain Safe Ambient Temperatures for Residents
Penalty
Summary
The facility failed to maintain ambient room temperatures within the regulatory range of 71-81 degrees Fahrenheit, affecting 116 residents. Observations and interviews revealed that certain resident rooms and common areas, particularly those exposed to direct sunlight, consistently exceeded the maximum allowable temperature, with readings as high as 88 degrees Fahrenheit. Staff reported that the facility's rooftop air conditioning units were old and insufficient, leading to the use of portable air conditioning units and fans. However, these portable units initially caused circuit breakers to trip, requiring adjustments to their placement. Temperature checks were reportedly conducted early in the morning, before outside temperatures rose, and weekly monitoring was performed by the maintenance director. A resident reported having to unplug personal devices to use a portable air conditioner, which would sometimes trip the circuit breaker. Despite the facility's efforts to supplement cooling with portable units and fans, multiple areas remained above the required temperature range during surveyor checks. Review of the facility's temperature monitoring logs for the previous 75 days did not show any recorded temperatures outside the regulatory parameters, despite surveyor findings to the contrary.
Failure to Provide Palatable, Appetizing, and Properly Tempered Meals
Penalty
Summary
Surveyors identified a deficiency in the facility's food service, specifically related to the palatability, temperature, and presentation of meals provided to residents. Multiple residents reported that food was often served cold, dry, or unappetizing, with specific complaints about hard waffles, cold biscuits and gravy, dry bread, and repetitive menus. Observations confirmed that food trays were sometimes left in insulated carts for extended periods before being delivered, resulting in meals being served at improper temperatures. Temperature checks revealed that hot foods were not consistently maintained at safe temperatures, and cold items such as juice were served above recommended temperatures. Additionally, condiments and food preferences were frequently not honored, with residents receiving items they had previously declined or not receiving requested items such as peanut butter sandwiches or condiments like butter, salt, and pepper. Interviews with dietary staff and review of facility policies revealed that while there were procedures in place for tray accuracy and honoring food preferences, these were not consistently followed. Staff acknowledged that condiments should be included based on tray tickets, but residents routinely reported missing condiments. The dietary manager and registered dietitian indicated that audits to ensure tray accuracy were planned but had not yet been implemented. Bread deliveries were only made once a week, contributing to complaints about stale and hard bread. Food palatability tests conducted by the surveyor further confirmed issues with meal presentation, taste, and portion sizes, with meals described as bland, overcooked, and lacking in visual appeal. The deficiency affected a significant number of residents who rely on the facility for their nutritional needs, with reports of decreased food acceptance and the potential for nutritional decline. Residents expressed dissatisfaction with the quality and variety of meals, and some reported skipping facility meals altogether. The facility's failure to consistently provide palatable, appetizing, and appropriately tempered food, as well as to honor resident preferences and provide necessary condiments, directly contributed to the deficiency cited by surveyors.
Delayed Meal Service and Failure to Meet Resident Preferences
Penalty
Summary
The facility failed to provide timely meal service in accordance with residents' needs, preferences, and requests, as evidenced by observations, interviews, and record reviews. One resident reported that breakfast was served around 9:00 - 9:30 A.M., lunch from 1:00 - 1:30 P.M., and dinner from 6:00 - 6:30 P.M. On the day of observation, the resident's lunch tray was seen stored in an insulated transport cart in the hallway at 1:57 P.M., and was not delivered until 2:04 P.M. by a CNA, who then assisted the resident with feeding. The facility's policy indicated that lunch should be served between 12:00 and 2:00 P.M. This delay in meal delivery affected up to 116 residents who consume food at the facility, increasing the likelihood of delayed meal service, emotional or psychosocial distress, and decreased food acceptance or nutritional decline. The deficiency was identified through direct observation of meal service practices, interviews with residents, and review of facility policies and procedures regarding meal times and the availability of alternative meals and snacks.
Deficiency in Egress Door Locking Arrangements
Penalty
Summary
A deficiency was identified regarding the facility's egress doors, which are part of the required means of egress. The doors were found to be equipped with latches or locks that require the use of a tool or key from the egress side, which is not permitted unless specific special locking arrangements are in place. The report outlines that for clinical needs or security threat locking, only one locking device is allowed per door, and staff must have reliable means for rapid removal of occupants, such as remote control, keyed access, or other reliable methods. Additionally, for special needs locking arrangements, the locks must be electrical and fail-safe, releasing upon power loss, and the area must be protected by both a supervised automatic sprinkler system and a complete smoke detection system, with both systems arranged to unlock the doors upon activation. The report further details that delayed-egress, access-controlled, and elevator lobby exit access locking arrangements are only permitted under specific conditions, such as the presence of approved fire detection and sprinkler systems. The deficiency was cited because the facility did not meet these requirements as evidenced by the survey findings. No specific information about individual residents or their medical conditions is provided in the report.
Noncompliance with Corridor Door Fire and Smoke Resistance Requirements
Penalty
Summary
A deficiency was identified regarding corridor doors and doors protecting corridor openings, which did not meet regulatory requirements for resisting the passage of smoke and fire. The report notes that doors in areas other than required enclosures of vertical openings, exits, or hazardous areas must be constructed of 1 3/4 inch solid-bonded core wood or other approved materials capable of resisting fire for at least 20 minutes, unless the smoke compartment is fully sprinklered, in which case only smoke resistance is required. Additionally, corridor doors and doors to rooms containing flammable or combustible materials must have positive latching hardware, and roller latches are prohibited. The clearance between the bottom of the door and the floor covering must not exceed 1 inch, and there must be no impediment to the closing of the doors. The report also specifies requirements for powered doors, hold open devices, protective plates, Dutch doors, and door frames. The deficiency was cited due to noncompliance with one or more of these requirements, as evidenced by the survey findings.
Failure to Timely Revise Care Plan for Resident's Sexual Behaviors
Penalty
Summary
The facility failed to revise and implement a comprehensive care plan addressing a resident's sexual behaviors following a significant incident. The resident, who had Alzheimer's disease and was deemed incompetent to make medical decisions, exhibited severe mental impairment as indicated by low BIMS scores. On one occasion, the resident was found in bed with a female resident, with his hand down her pants. Although staff attempted to keep the resident separated from female residents and initiated one-on-one supervision, this intervention was not formalized through a physician's order or documented in the care plan. There was no clear communication or documentation to ensure all staff were aware of the supervision requirement. Subsequent incidents occurred, including the resident being found naked in bed with another female resident, again without evidence of one-on-one supervision being in place. Interviews with staff revealed confusion and lack of awareness regarding the supervision status, and assignment sheets did not reflect any one-on-one supervision for the resident. The care plan was not updated to address the resident's sexual behaviors and the need for one-on-one supervision until after these incidents had occurred, indicating a failure to timely revise the care plan in response to the resident's behaviors.
Failure to Provide One-on-One Supervision for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide one-on-one supervision for a resident with severe mental impairment and a diagnosis of Alzheimer's disease, despite documented incidents of inappropriate sexual behavior with other residents. The resident had a Brief Interview for Mental Status (BIMS) score indicating severe impairment and was deemed incompetent to make medical decisions. Progress notes revealed that staff had been attempting to keep the resident separated from female residents, but the resident was found in bed with a female resident on multiple occasions, including incidents where inappropriate sexual contact occurred. Although a plan for one-on-one supervision was mentioned in progress notes, it was not formalized as a physician's order, and there was no consistent documentation or communication to ensure all staff were aware of the supervision requirement. Interviews with staff indicated a lack of clarity and documentation regarding the implementation of one-on-one supervision. Some staff members were unaware of the supervision requirement, and assignment sheets did not reflect that one-on-one supervision was in place for the resident. Additionally, behavior monitoring logs and daily assignment sheets lacked documentation of the resident's behaviors and supervision status. The absence of clear orders, documentation, and communication led to repeated incidents where the resident was unsupervised and engaged in inappropriate behavior with other residents.
Failure to Prevent and Identify Pressure Ulcers
Penalty
Summary
The facility failed to prevent and correctly identify pressure ulcers for two residents, leading to misidentification and worsening of their conditions. Resident 101, who had a spinal cord injury and contractures, was observed to have a stage III pressure ulcer on the right buttock, which was initially documented as new. However, the facility's documentation was inconsistent, with no granulation observed in the wound photos, and the resident's skin assessments were incomplete, missing several months. The care plan for Resident 101 did not address the moisture-associated skin damage (MASD) or the stage III pressure ulcer, and the resident's refusals of care were not adequately managed or documented. Resident 108, who had been residing in the facility since October 2024, reported having a painful pressure ulcer on the right foot and another on the buttock. The facility's documentation showed inconsistencies in staging the sacral wound, which was initially identified as unstageable but was later observed to be a stage IV wound. The care plan for Resident 108 did not address the resident's refusals to reposition or coordinate care with Hospice, despite the resident's high risk for skin breakdown due to malnutrition and terminal diagnosis. The facility's interventions were not fully implemented, and there was a lack of documentation on the coordination of care with Hospice. Interviews with staff revealed a lack of awareness and understanding of the residents' wound conditions and the appropriate staging of pressure ulcers. The wound care nurse and the Director of Nursing did not perform root cause analyses or develop plans to prevent further pressure ulcers. The facility's failure to conduct regular skin assessments, update care plans, and implement effective interventions contributed to the deterioration of the residents' pressure ulcers.
Deficiency in Food Quality and Temperature Control
Penalty
Summary
The facility failed to provide palatable and appropriately temperature-controlled food to its residents, affecting 119 individuals. Observations and interviews revealed that food items were often served at temperatures below the standards set by the 2022 FDA Model Food Code. For instance, during meal service, items such as hamburgers, mashed potatoes, and broccoli were recorded at temperatures below the required 135°F, leading to dissatisfaction among residents. Additionally, beverages like apple juice were served at temperatures above the recommended 41°F, further contributing to the issue. Residents expressed dissatisfaction with the quality and temperature of the food. Several residents reported that meals were often cold, unappetizing, and lacked flavor. Some residents mentioned that the food was tough and difficult to cut, while others noted that the meals were repetitive and of poor quality. Interviews with residents revealed that these concerns had been ongoing, with some residents stating that they had raised these issues with the dietician, but little had changed. The facility's dietary management practices were also scrutinized. The Dietary Manager and Registered Dietician acknowledged receiving complaints about cold food and had instituted temperature audits. However, the audits revealed consistent issues with food temperatures, as documented in the Test Tray Audit Worksheet. Despite these audits, residents continued to report dissatisfaction with the food, indicating a lack of effective resolution to the problem. The facility's failure to address these concerns adequately resulted in a deficiency in providing palatable and safe meals to its residents.
Deficiencies in Food Service Equipment Maintenance and Sanitation
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, impacting 119 residents and increasing the likelihood of cross-contamination and bacterial harborage. During an initial tour of the food service area, it was observed that two can opener assemblies and their mounting brackets were soiled with accumulated and encrusted food residue. The Dietary Manager acknowledged the issue and indicated that staff would clean and sanitize the equipment. Additionally, clear plastic scoops used for dry food products like flour and oatmeal were stored improperly within the food product storage bins, contrary to the 2022 FDA Model Food Code requirements. Further observations revealed that the dry storage room's return-air-ventilation grill was loose, with five of six mounting screws missing, which could compromise the facility's physical integrity. The facility's policies on maintenance and repairs, as well as dietary cleaning and sanitation, were reviewed, indicating that malfunctions and repair needs should be reported promptly, and that the kitchen should be maintained to minimize microorganism growth. However, these policies were not effectively implemented, leading to the noted deficiencies.
Failure to Reassess Facility Needs and Involve Governing Body
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment that included input from the Governing Body and did not reassess the facility's ability to meet resident care needs following a change in resident acuity status. The last assessment was conducted on 7/16/2023 and was valid through 7/15/2024. However, within the last 30 days, the facility experienced seven pressure ulcers requiring treatment, 42 resident falls with two resulting in major injuries, and 13 residents requiring catheter care. Despite these changes, the facility did not reassess its capacity to meet these care needs. Additionally, the assessment incorrectly listed the Administrator as the Governing Body, rather than the owner, CEO, or other legally responsible individuals. The Administrator was unaware that she was accountable to the Governing Body and not the Governing Body herself.
Facility Maintenance Deficiencies Affect Resident Safety and Cleanliness
Penalty
Summary
The facility failed to maintain a clean and safe environment, affecting 119 residents, as evidenced by multiple deficiencies observed during an environmental tour. The outdoor smoking area canopy was found to be worn, warped, and missing, allowing weather elements to enter the space. A resident reported that the canopy had been in poor condition for the entire three years of their stay. Additionally, the laundry service area had issues such as a porous folding table surface, cracked light lens covers, and non-functional light assemblies, which could lead to bacterial harborage and decreased air quality. Further observations revealed numerous maintenance issues throughout the facility, including leaking water valves, broken light covers, and non-functional light assemblies in soiled utility rooms. The occupational therapy/physical therapy area had a corroded microwave oven, and the staff/visitor restroom had deteriorated caulking. The nurses' station restroom had an ill-fitting commode seat, and the PPE storage room had flooring issues. Shower rooms were missing atmospheric vacuum breakers, and several areas had cracked or missing tiles, contributing to potential cross-contamination risks. The facility's maintenance department policies were reviewed, revealing a lack of specific entries related to the observed maintenance concerns in the Direct Supply TELS Work Orders for the last 85 days. This indicates a failure in the ongoing monitoring and reporting system for necessary repairs, as outlined in the facility's maintenance and housekeeping policies. The environmental services supervisor acknowledged the issues and indicated plans to contact maintenance for repairs, but the deficiencies remained unaddressed at the time of the survey.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Agency involving a resident with moderate cognitive impairment due to dementia. The resident reported being physically and verbally abused by a Certified Nursing Assistant, and the Nursing Home Administrator (NHA) and Social Worker (SW) were notified. Despite the resident's inability to provide a physical description or name of the alleged perpetrator, the SW interviewed the resident and their spouse, concluding that the abuse was not substantiated due to the resident's confusion. Consequently, the incident was not documented in the clinical record nor reported to the State Agency. During interviews, the SW indicated that the decision not to report was made by the NHA, who also confirmed the incident was not reported because it was deemed unsubstantiated. However, the facility's policy requires reporting all allegations of abuse to the State Agency within specified timeframes, regardless of substantiation. The NHA acknowledged that the facility frequently self-reports to the State Agency, even when abuse is unsubstantiated, but could not explain why this particular incident was not reported. The facility's policy mandates that the results of any investigation, substantiated or not, be reported to the State Agency within five working days, which was not adhered to in this case.
Failure to Implement Comprehensive Care Plans for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their skin integrity needs. Resident 101, who had a spinal cord injury and contractures, developed a stage III pressure ulcer on the buttocks, which was not adequately addressed in the care plan. The care plan was outdated and did not include interventions for the resident's moisture-associated skin damage (MASD) or the pressure ulcer. Additionally, the resident's refusals of care, such as turning and repositioning, were not documented or addressed in the care plan. Resident 108, who was on hospice care and had a high risk for skin breakdown, developed pressure ulcers on the right foot and sacrum. The facility's documentation indicated that these pressure ulcers were unavoidable due to the resident's malnutrition and terminal diagnosis. However, the care plan did not include interventions to address the resident's refusals to reposition or coordinate care with hospice services. The facility also failed to document interventions such as off-loading bony prominences and using positioning devices, which were noted in other documents but not in the care plan. Interviews with facility staff revealed a lack of root cause analysis and documentation regarding the residents' pressure ulcers. The Licensed Practical Nurse (LPN) and Registered Nurse (RN) involved in wound care did not perform thorough assessments or document discussions about the residents' wounds in Quality Assurance Performance Improvement (QAPI) meetings. The Director of Nursing (DON) acknowledged the lack of audits and root cause analysis to ensure the healing of current wounds and prevention of further wounds, indicating systemic issues in the facility's approach to wound care management.
Failure to Revise Care Plan for Resident with Contractures
Penalty
Summary
The facility failed to appropriately revise the care plan interventions for one resident, identified as R101, who had been residing at the facility since April 2023. R101 had diagnoses including contractures of the right and left hand and muscles. A care plan dated January 2025 indicated that R101 had contractures in bilateral ankles, wrists/hands, and elbows, with interventions to provide assistive devices such as hand and elbow splints. However, observations on multiple occasions in March 2025 revealed that R101 was not wearing the prescribed splints, and they were found lying on the over-bed table instead. R101 reported that the splints no longer fit because staff did not put them on, and a washcloth was observed in R101's left hand instead of the splints. Interviews with staff, including a CNA, LPN, and a Certified Occupational Therapy Assistant (COTA), revealed inconsistencies in the implementation of the care plan. The CNA mentioned that R101 was offered the splints every two hours but may refuse them, while the LPN was unaware of how often the splints were offered. The COTA stated that R101 was evaluated in March 2025, and it was recommended that R101 wear bilateral hand/wrist splints since November 2024. However, the COTA was not informed of any refusal by R101 to wear the splints. The care plan had not been updated with new interventions following the therapy's recommendations in March 2025, indicating a failure to revise the care plan appropriately based on the resident's current needs and therapy recommendations.
Failure to Provide Podiatry Care for Resident
Penalty
Summary
The facility failed to provide necessary podiatry care for a resident diagnosed with dementia, who was admitted with moderate cognitive impairment. The resident's family member, who visited daily, expressed frustration over the facility's inaction despite multiple requests for podiatry services over approximately five months. The family member had been attempting to manage the resident's toenail care themselves, despite the difficulty due to the thickness and curling of the nails. During an observation, the resident's second toenail was noted to be excessively long and curled under the toe, covering the pad of the toe. Interviews with facility staff revealed a lack of communication and responsibility regarding the arrangement of podiatry services. The social worker claimed no responsibility for arranging ancillary services and did not acknowledge the family's requests. The medical records staff confirmed receiving a request for podiatry care from the family member about a month prior but had not ensured the resident was seen by a podiatrist. The LPN/Unit Manager was unaware of the resident's need for podiatry care and acknowledged that the nursing staff should have documented and addressed the condition of the resident's toenails during routine assessments.
Failure to Implement Prescribed ROM Interventions for Resident
Penalty
Summary
The facility failed to ensure that a resident, who had been diagnosed with contractures of the right and left hands and muscles, received appropriate care to maintain or improve range of motion. The resident, who had been residing at the facility since April 2023, was observed on multiple occasions without the prescribed hand splints and positioning wedge in place. The care plan and CNA Kardex indicated that the resident should have been provided with right and left hand splints and elbow splints, but these were not being utilized. The resident reported that staff never turned him, and he was always on his back, with the wedge meant for repositioning left unused on the bedside table. Interviews with staff revealed inconsistencies in the application of the splints. A CNA mentioned that the resident was offered the splints every two hours but may refuse them, although no specific reason was provided for the resident's refusal. The LPN was unaware of how often the splints were offered, and the COTA stated that the resident should have been wearing the splints since they were recommended in November 2024. The therapy plan of treatment recommended the use of resting hand and elbow extension splints for four hours on and four hours off to improve passive range of motion, but the care plan had not been updated with these recommendations.
Failure to Document Physician Review of Medication Irregularities
Penalty
Summary
The facility failed to ensure that the attending physician documented the review of identified medication irregularities, the actions taken, or the rationale for not making changes to the medications for a resident. The resident, who was admitted for long-term care and resided in the facility's secured dementia unit, had a low score on the Brief Interview for Mental Status, indicating cognitive impairment. The Monthly Medication Review noted that the resident was receiving Divalproex and had experienced recent mental status changes, including agitation and anxiety. The pharmacist recommended monitoring serum ammonia concentration and valproic acid levels due to potential adverse effects, but the physician did not document any response to these recommendations. During an interview, the Director of Nursing (DON) explained the process for handling pharmacist recommendations, which involved electronic delivery, printing, and placement in a binder for the physician or nurse practitioner to review and sign. However, the DON was unable to find any documentation from the provider regarding lab orders for valproic acid or any agreement or disagreement with the pharmacist's recommendations. The provider's signed pharmacy recommendation was also missing, and the DON could not explain why the physician had not addressed the recommendation.
Failure to Meet Residents' Nutritional Needs and Preferences
Penalty
Summary
The facility failed to meet the nutritional needs and food preferences of two residents, R28 and R117, as observed during a survey. Resident 28 expressed dissatisfaction with the inconsistency in receiving a chef salad, which was supposed to be a regular part of their meal plan. Despite having a standing order for a chef salad, R28 reported receiving it only about once a week, and sometimes it was just plain lettuce without the desired toppings. Additionally, R28 received a meal with barbecue sauce, which was listed as a dislike on their meal ticket, indicating a failure to adhere to dietary restrictions. Resident 117, who has a history of depression, anxiety, COPD, and congestive heart failure, was found to be underweight with a BMI of 13.6. R117 reported that meals were often served cold and did not match the items listed on their meal ticket, such as side salad, fresh grapes, and nutritional juice. The resident also noted that the meal cart sat in the hallway for extended periods before trays were distributed, contributing to the cold meals. Despite having standing orders for certain items, these were not consistently provided, and the resident expressed frustration over the lack of oversight in meal preparation and delivery. The Dietary Manager acknowledged issues with food availability and preparation, citing instances where fresh produce was not available and substitutions were not communicated to residents. The manager also confirmed that certain items, like grapes, were out of stock, and admitted that the staff might have rushed meal preparation, leading to errors in fulfilling residents' meal preferences. The facility's policy on food preferences was not effectively implemented, resulting in residents not receiving appropriate meals as per their dietary needs and preferences.
Failure to Address Pressure Ulcers in QAPI Committee
Penalty
Summary
The facility failed to identify the need for an action plan for pressure ulcers through its Quality Assurance Performance Improvement (QAPI) committee. During an onsite survey, it was found that two out of six residents reviewed had developed facility-acquired pressure ulcers at stage III or higher. The facility's policy requires the QAPI committee to meet regularly to develop and implement plans to correct quality deficiencies, but this was not done for pressure ulcers. The wound nurse, LPN K, admitted to not performing a root cause analysis for the pressure ulcers and only verbally discussing the residents' wounds in QAPI meetings without documentation. The Director of Nursing (DON B) stated that she assisted the wound care nurses in obtaining necessary equipment but did not conduct audits or root cause analyses to prevent further pressure ulcers. The Administrator acknowledged that the QAPI committee was working on assessing residents' risk for skin breakdown but had not identified residents with current pressure ulcers or developed a performance improvement plan. There were no audits or assessments available for residents with pressure ulcers, indicating a lack of systematic approach to address and prevent pressure ulcers in the facility.
Failure to Prevent Misappropriation of Resident's Debit Card
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's belongings, specifically a social security debit card, which resulted in feelings of loss of independence and potential mistrust. The resident, who had intact cognition, reported that an Activities Aide (AA) had assisted him with an online purchase and was the last known person to have possession of his debit card. The resident was informed by the police that the AA was arrested and charged with felonies for unauthorized use of the card. The resident expressed a desire for restitution rather than punishment for the AA, as the incident led to his brother managing the card, causing a delay in his ability to make personal purchases. The facility's investigation revealed that the resident's debit card was missing after he returned from a hospital stay. The police were notified, and a report was filed. The investigation showed unauthorized transactions, including online gaming purchases and fast-food orders, made while the resident was hospitalized. The police identified the AA as the perpetrator through video footage and transaction records. Despite the facility's initial inability to substantiate the misappropriation, the police investigation confirmed the AA's involvement, leading to his arrest and termination from the facility.
Inappropriate Use of Restraints on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which were imposed for convenience rather than medical necessity. The resident, who had severe cognitive impairment and required assistance for mobility, was observed attempting to exit his bed independently. A foam wedge was placed under the fitted sheet, seemingly to prevent the resident from leaving the bed, which restricted his mobility. Staff members, including a CNA and an LPN, were unsure of the purpose of the wedge, indicating a lack of clear communication and understanding of its use. The resident had a history of falls and was known to be active, often propelling himself around the unit in a manual wheelchair. However, staff frequently placed him in a geri-chair, which he could not propel, further restricting his movement. The resident's care plan included interventions to prevent falls, such as positioning him in view of staff, but these were not effectively implemented. Interviews with staff and family members revealed that the resident was often kept in the geri-chair to prevent him from moving, and a standard chair was used to immobilize the geri-chair's footrest, indicating the use of restraints for convenience. The Director of Nursing acknowledged that the wedge should be used for positioning and that the resident should be allowed to move freely in a manual wheelchair when awake and active. Despite this, the resident was often restrained in a geri-chair, and there was no work order for the chair, suggesting it may have been broken. The facility's actions and inactions led to the inappropriate use of restraints, restricting the resident's mobility and potentially impacting his physical and psychosocial well-being.
Delay in X-ray Leads to Untimely Treatment for Resident's Fracture
Penalty
Summary
The facility failed to obtain a timely x-ray for a resident, resulting in a delay in treatment for a hip and femur fracture. The resident, who had severe cognitive impairment and was a known fall risk, experienced multiple falls within the facility. Despite interventions to position the resident in view of staff, the resident continued to fall, including an unwitnessed fall on 9/20/24. Following this fall, significant bruising and swelling were observed, and a stat x-ray was ordered on 9/24/24. However, the x-ray was not completed promptly. The nursing staff noted the resident's condition, including swelling and inability to move the left leg, and contacted the radiology service for a status update. Despite these efforts, the x-ray service did not arrive until after the resident was transferred to the hospital on 9/25/24. The hospital confirmed the resident had a femoral shaft fracture and a chronic femoral neck fracture, requiring operative fixation. Interviews with staff revealed that the resident was often restless and attempted to get out of bed, leading to the use of a wedge to prevent falls. The Director of Nursing acknowledged the delay in obtaining the x-ray and the need for staff supervision during the resident's unwitnessed fall. The interdisciplinary team was discussing the concerns regarding the delay in obtaining the x-ray.
Failure to Prevent Falls and Delay in Medical Imaging
Penalty
Summary
The facility failed to develop and implement effective interventions to prevent falls for a resident, resulting in a fall with a major injury. The resident, who had severe cognitive impairment and required assistance for transfers, was observed attempting to get out of bed independently. The only measure in place to prevent the resident from exiting the bed was a foam wedge, which was not properly positioned. Staff members, including a CNA and an LPN, were unaware of the purpose of the foam wedge, indicating a lack of communication and understanding of the resident's care plan. The resident had a history of falls, with multiple incidents reported in the months leading up to the major injury. Despite these falls, the interventions listed in the care plan were inadequate, such as encouraging positioning near staff in the day room. The resident was known to be mobile and able to self-propel in a wheelchair, yet was often placed in a geri-chair, which restricted movement and contributed to the resident's restlessness and attempts to exit the chair. The use of a standard chair to immobilize the geri-chair's footrest further limited the resident's ability to move safely. Additionally, there was a significant delay in obtaining a stat x-ray after the resident's family reported swelling and bruising, which was indicative of a fracture. The x-ray was ordered but not completed in a timely manner, leading to a delay in the resident's transfer to the hospital for appropriate care. Interviews with staff revealed a lack of consistent supervision and inadequate fall prevention strategies, contributing to the resident's fall and subsequent injury.
Failure to Ensure Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure the safety and proper supervision of a resident, resulting in a fall and subsequent injury. The resident, a cognitively intact female with a history of cerebral vascular accident and other medical conditions, was not properly positioned in a shower chair by a CNA. The CNA left the resident unattended to seek assistance, during which time the resident began to slide forward and was lowered to the floor. Despite the fall, the resident was moved back into the shower chair and the shower was completed without notifying a nurse or conducting an immediate assessment. The incident was not reported to the nursing staff until approximately two hours later when the resident's husband alerted the nurse to the resident's pain. The resident was found to have a swollen left knee and was later diagnosed with a left distal femur fracture. The facility's care plan, which required a Hoyer lift for transfers, was not followed, and the incident report lacked a thorough investigation. The resident experienced increased pain and required additional pain medication following the fall. Interviews with staff revealed a lack of adherence to the facility's fall management policy, which mandates that residents not be moved after a fall until assessed by a nurse. The CNA involved in the incident was terminated, and the facility acknowledged past non-compliance with fall supervision. Despite the facility's policy and staff education on fall prevention, the incident highlighted deficiencies in communication and adherence to care plans.
Failure to Prevent Repeated Falls Due to Lack of Supervision
Penalty
Summary
The facility failed to implement effective interventions to prevent repeated falls for a resident with Alzheimer's Disease, who was reviewed for accidents and supervision. The resident, who had severely impaired cognition and a history of falls, was observed multiple times in the day room without adequate supervision or engagement from staff. Despite the presence of staff, including CNAs and an RN, there was a lack of interaction with the residents, which was noted during several observations by the surveyor. The resident had a history of ten falls since March 2024, with incidents occurring in various locations such as the day room, hallway, and her room. The falls were often related to the resident's behavior of moving furniture or attempting to stand unassisted. Although some interventions were documented, such as medication adjustments and providing diversional activities, there was no in-depth analysis of the root causes of the falls or consistent implementation of interventions. For instance, a recommended chair by the exit door was not observed during the surveyor's visits. The Director of Nursing acknowledged the need for more engagement and interaction with residents to prevent falls but did not provide a response regarding the evaluation of staffing needs or the implementation of interventions. The facility's fall management policy emphasized identifying hazards and implementing interventions to minimize falls, but the observations and documentation indicated a failure to adhere to this policy effectively.
Inadequate Supervision and Care on Unit 3
Penalty
Summary
The facility failed to ensure adequate care and supervision on Unit 3, which housed residents with cognitive impairments, including a resident with Alzheimer's Disease who had a history of falls and impaired cognition. On the day of the incident, a complaint was submitted regarding the absence of staff on the unit, which was observed by a family member returning a resident from an overnight leave of absence. The family member noted that there was no nurse present to receive the resident's medications, and the only visible staff was an activities aide in the day room. This lack of supervision led to residents being unassisted, with some attempting to leave the unit or access restricted areas. The investigation revealed that the assigned Registered Nurse (RN) for Unit 3, RN 'F', had taken an extended break without ensuring proper coverage. RN 'F' combined her lunch and two 15-minute breaks, leaving the unit for approximately an hour without informing another nurse or handing over the medication cart keys. During her absence, the Certified Nursing Assistants (CNAs) assigned to the unit were also not present, as one CNA had left to inform another unit of her departure time, leaving only the activities aide with the residents. This lack of coordination and communication among staff resulted in inadequate supervision and care for the residents. The Director of Nursing (DON) confirmed that the facility's protocol was not followed, as RN 'F' did not report her extended break to another nurse or ensure the medication cart was accessible. Additionally, CNA 'K' did not remain on the unit or seek assistance from another nurse when the family expressed concerns. The failure to adhere to established protocols for staff breaks and coverage led to a deficiency in maintaining professional standards of care and supervision for the residents on Unit 3.
Failure to Monitor Blood Pressure Before Medication Administration
Penalty
Summary
The facility failed to monitor and document blood pressures for a resident with hypertension, which was necessary to ensure the proper administration of prescribed medication. The resident, who had severely impaired cognition, was admitted with a physician's order for amlodipine, a medication to be held if the systolic blood pressure was less than 100 mmHg. However, the Medication Administration Record for May and June 2024 showed no documentation of the resident's blood pressure, despite the medication being administered daily since the order was given. Interviews and record reviews revealed that the Director of Nursing acknowledged the lack of consistent documentation of the resident's blood pressures in the clinical record. The order was not properly entered to ensure monitoring before administering the medication. The facility's policy on medication administration required vital signs to be taken prior to administering doses when applicable, but this was not followed, leading to the deficiency.
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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