Shorepointe Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in St. Clair Shores, Michigan.
- Location
- 26001 East Jefferson Avenue, St. Clair Shores, Michigan 48081
- CMS Provider Number
- 235443
- Inspections on file
- 33
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Shorepointe Nursing Center during CMS and state inspections, most recent first.
A resident with quadriplegia and moderate cognitive impairment, who required two-person assistance for bed mobility, fell and sustained injuries when only one CNA was present during care. The resident became anxious, attempted to hold onto the bed sheet, and rolled off the bed. Documentation and interviews confirmed that the care plan requiring two-person assistance was not followed, and the facility's policy did not address fall prevention procedures.
The facility failed to provide adequate meal portion sizes, potentially affecting residents' nutritional intake. A dietary staff member used a 6-ounce ladle instead of the required 8-ounce portion for chili, confirmed by the Certified Food Manager. Residents also reported insufficient food portions, such as receiving only one rib or one slice of pizza during meals.
The facility was found deficient in food safety practices, with issues such as black debris in the ice scoop holder, dusty ice machine filter, and soiled microwaves. The dish machine's sanitization log was incomplete, and chlorine sanitizer was not detected. Unlabeled spray bottles and mold-like substances were also observed, indicating a failure to maintain cleanliness and proper labeling.
The facility failed to provide person-centered care plans for two residents, one with PTSD and Vascular Dementia, and another with moderate cognitive impairment and non-compliance issues. The first resident's care plan lacked provisions for their specific diagnoses, while the second resident, who often refused care and dietary restrictions, had no care plan addressing their non-compliance. Staff acknowledged these deficiencies, which were not in line with the facility's Behavioral Care Services policy.
A resident experienced delays in receiving ADL care, with their call light out of reach and ignored by staff. The resident, dependent on staff for toileting due to respiratory failure and COPD, waited over an hour for assistance. Multiple staff members failed to respond to the call light, and a group of residents reported similar issues when agency staff were on duty.
A resident received inappropriate medication administration via a PEG tube, with an LPN failing to follow the facility's policy on water flush amounts and medication combination. The resident reported feeling full and nauseous after the administration. Interviews with staff revealed inconsistencies in understanding and applying the facility's policy.
A facility failed to maintain a medication error rate below five percent, resulting in a 12.82% error rate. An LPN administered nine crushed medications via a PEG tube to a resident, combining the last five medications despite no order to do so. The resident felt full and nauseous, and residual medication was left in the syringe. Facility policy mandates separate administration of each medication.
A resident with a history of stroke and heart disease did not receive blood pressure medication, Clonidine, as needed according to physician orders. Despite multiple elevated blood pressure readings, the facility failed to administer the medication and notify the physician, as required. The resident's MAR showed only two administrations of the PRN Clonidine, and the Unit Manager confirmed the expectation to follow orders and report elevated readings.
The facility failed to properly label and discard expired medications, as observed in several medication carts and a medication room. Items such as dorzolamide eye drops, insulin vials, and inhalers were found without proper labeling or were expired. The DON confirmed the need for proper labeling and discarding of expired medications.
A resident's tube feeding pole was observed with a thick layer of dried tube feed and missing labeling on the feeding bag. Used gloves and wet fluid were found on the floor. The Infection Control Preventionist indicated the pole should be cleaned when soiled, but this was not done, violating the facility's cleaning policy.
The facility failed to ensure call lights were accessible to residents, as observed in three cases where call lights were found on the floor, out of reach. One resident with intact cognition required substantial assistance for ADLs, while another with moderately impaired cognition needed moderate assistance. A third resident, also with moderately impaired cognition, was dependent on staff for toileting. The facility's policy requires call lights to be within reach, but this was not consistently adhered to.
Two residents were found to lack required care plans: one with PTSD and Vascular Dementia had no care plan addressing these diagnoses, and another, dependent for most ADLs and with a history of non-compliance, had no care plan for refusal of care or dietary non-adherence. Staff confirmed the omissions, despite facility policy requiring care plan development based on assessment.
A resident with respiratory failure, muscle weakness, and moderately impaired cognition was twice observed to have their call light on the floor and out of reach. During one observation, an LPN was present and placed the call light within reach after being questioned. Another LPN confirmed that call lights should be accessible to residents at all times.
A call light was found on the floor and out of reach for a resident with impaired cognition, incontinence, and dependence on staff for toileting, despite facility policy and administrative expectations that call lights be accessible at bedside.
Surveyors found that multiple emergency exit doors, which were labeled as having a 15-second delayed-egress with alarm, opened freely without resistance or alarm activation when tested. This failure to maintain the required delayed-egress locking and alarm systems was confirmed with the Maintenance Director.
Multiple ceiling-mounted exit signs on the 2nd and 3rd floors were found to be inoperative, lacking the required continuous illumination and emergency lighting backup. This deficiency was confirmed by the Maintenance Director during surveyor observations.
The facility did not provide evidence of required semi-annual servicing or monthly owner inspections for its range hood suppression system, with the last documented service occurring over a year ago. These documentation lapses were confirmed during record review with the Maintenance Director.
Surveyors observed that the fire alarm remote panel in the vestibule to Physical Therapy was displaying incorrect date and time information, indicating the system was not properly tested and maintained according to NFPA 70 and NFPA 72 requirements. This issue was confirmed by the Maintenance Director and could impact all residents in the event of a fire.
Multiple deficiencies were identified in the maintenance and testing of the facility's automatic sprinkler system, including missing or damaged ceiling tiles, absent or incomplete sprinkler components, dirty sprinkler heads, and improper storage near sprinkler heads. Required documentation for quarterly flow tests was also not provided, with these issues confirmed by the Maintenance Director.
Surveyors identified that combustible items were stored too close to electrical panels and a transformer, and that an electrical panel cover was disassembled and open blanks were present in another panel. These deficiencies were confirmed by the Maintenance Director and could affect all residents in the event of an electrical fire.
Surveyors found that the facility did not provide documentation of the required quadrennial fire damper inspection, with the last recorded servicing over four years ago. This deficiency was confirmed with the Maintenance Director and could impact all residents in the event of a fire.
Nursing staff on an upper floor reported not receiving training on evacuation procedures for moving residents to the ground level when elevators are unavailable or during a fire. This was confirmed by the Maintenance Director, indicating a lack of compliance with required emergency preparedness training.
The facility did not conduct required fire drills at unexpected times or under varying conditions, instead holding them at similar, predictable times for both 1st and 2nd shifts. This deficiency was confirmed by record review and interview with the Maintenance Director, and could affect all residents in the event of a fire.
Surveyors found that emergency backup power generators had unsecured access panels and lacked required handle locks, and the facility could not provide documentation for annual servicing, load bank testing, monthly load tests, or annual fuel analysis. These deficiencies were confirmed with the Maintenance Director.
An observation revealed that the electronic stairway path interrupter on the 2nd floor egress by the elevators was not functioning, which could cause individuals to miss the correct exit during an emergency. This issue was confirmed with the Maintenance Director and could affect a significant number of residents during a fire.
A fire extinguisher in the Physical Therapy Charting Room was found obstructed by combustible stock items, preventing proper access and maintenance as required by NFPA 10. This deficiency was confirmed by the Maintenance Director and could have affected multiple residents in the event of a fire.
Surveyors found that several smoke barrier doors, including those at the 2nd floor storage room, Physical Therapy, and sitting room, failed to positively latch when tested, and some lacked required self-closure devices. These deficiencies were confirmed with the Maintenance Director during the inspection.
Oxygen cylinders were found stored within five feet of combustible items in a clean linen room, in violation of NFPA 99 requirements for gas storage. This improper storage was confirmed by the Maintenance Director and could impact a significant number of residents in the event of a fire emergency.
A resident experienced fear and distress after a staff member misappropriated funds from their bank account and confronted them aggressively during an abuse investigation. Despite being suspended, the staff member was able to enter the resident's room, causing further intimidation. The facility failed to implement its abuse prevention policy effectively, resulting in the resident feeling unsafe.
A staff member at an LTC facility misappropriated a resident's funds by linking a gambling app to a joint bank account, resulting in unauthorized withdrawals of $18,368. The resident discovered the issue after noticing declined transactions and reported it to their family, who then involved the police. Despite being suspended, the staff member confronted the resident, causing fear and distress. The facility's failure to prevent this incident highlights a deficiency in protecting residents from financial exploitation.
The facility failed to notify two residents of room changes as required by policy. One resident's responsible party was informed two days after the move, while another resident was told just before the change without a chance to preview the new room. Both residents, with diagnoses including dementia, were dissatisfied with the changes, and there was no documentation of prior notification.
A resident with a history of falls and medical conditions was left unattended on a mechanical lift sling in a wheelchair, contrary to their care plan which included an anti-slip pad. The CNA realized the sling was the wrong size and left to get the correct one, during which the resident fell. The DON acknowledged the resident should not have been left unattended, and the facility lacked specific policy documentation for such situations.
A resident with severe cognitive impairment and a history of shoulder dislocations was improperly transferred using a sit to stand lift instead of the prescribed mechanical lift with two-person assistance. This led to a shoulder dislocation, as staff failed to review the Kardex for correct transfer instructions.
The facility failed to provide scheduled grooming and showering for two residents, leading to a deficiency in ADL care. One resident, with intact cognition, only received bed baths despite needing showers, which were not documented as a preference. Another resident, with impaired cognition, was unable to shave and reported staff unavailability for assistance, despite a care plan indicating the need for help with personal hygiene.
A resident with an indwelling catheter required a follow-up urology appointment after hospital discharge, which the facility failed to schedule. Despite attempts by the DON and Unit Clerk to arrange the appointment, there was no documentation of the efforts or physician notification. The facility's policy on scheduling external consultations was not followed.
The facility failed to provide palatable and properly heated meals, as residents reported receiving cold or barely warm food. Observations showed meals left uncovered on a steam table, and a test tray revealed food was not hot and lacked taste. The Tray Delivery Schedule was not followed, with delays in meal delivery. The Dietary Manager confirmed food temperatures were checked before plating but could not explain the delay.
Failure to Provide Required Supervision and Assistance During Resident Care Resulting in Fall
Penalty
Summary
A resident with quadriplegia, anxiety, muscle wasting, and moderate cognitive impairment, who required two-person assistance for bed mobility and transfers, experienced a fall while being cared for by a single CNA. The resident became anxious during care, attempted to hold onto the bed sheet, and subsequently rolled off the bed, resulting in a laceration above the right eyebrow and additional injuries. The resident was transported to the hospital for evaluation and treatment following the incident. Review of the resident's care plan and ADL documentation confirmed the need for two-person assistance during bed mobility and toileting. However, at the time of the fall, only one CNA was present and providing care. The facility's Accident and Injury policy, provided upon request, did not address specific procedures for fall prevention. Interviews with staff and the DON confirmed the circumstances of the fall and the lack of adherence to the resident's care plan requirements.
Inadequate Meal Portion Sizes in Facility
Penalty
Summary
The facility failed to ensure that meal portion sizes met the nutritional needs of the residents, which could potentially lead to inadequate protein intake, weight loss, and decreased meal enjoyment. During an observation, a dietary staff member was seen serving chili using a 6-ounce ladle, despite the production sheet indicating that the portion size should be 8 ounces. When questioned, the dietary staff member was unaware of the correct portion size, and the Certified Food Manager confirmed the error. Additionally, during a group meeting with eight residents, all participants expressed that the food portions were insufficient, citing examples such as being served only one rib or one slice of pizza during meals.
Plan Of Correction
Element 1: Cited Residents The facility failed to ensure meal portion sizes meet the nutritional needs of the residents. No specific residents were affected by these practices. Element 2: Like Residents Residents who reside in the facility have the potential to be impacted by the identified practice. The facility audited the serving ladles to ensure they are the proper size. Element 3: Education Dietary Director and Dietary staff will be educated on the acceptable ladle size of 8 oz. to ensure the serving size meets the nutritional needs of the residents. Element 4: Audits The administrator or designee will complete random audits on the kitchen tray line 5 meals a week for 4 weeks to ensure the acceptable ladle size of 8 oz. is being used to meet the nutritional needs of the residents. Element 5: Compliance The facility Administrator will be responsible for assuring substance compliance is attained through this plan of correction by 5/13/25 and for sustained compliance thereafter.
Deficient Food Safety Practices in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The ice scoop holder was found with black debris, and the ice scoop was resting in it. The ice machine filter was dusty, and the interior of the microwave had dried food debris. The walk-in cooler's floor was soiled with black stains and dried milk. In the chemical room, two unlabeled spray bottles were found, and the floor drain cover under the dish machine was obstructed with debris. The dish machine's sanitization log had not been completed since breakfast on 4/11, and the chlorine sanitizer was not detected during testing. Additionally, the 2nd floor nourishment room had a microwave with peeling paint and mold-like stains on towels under the sink. The 3rd floor nourishment room's microwave was rusty, and the shelf under the sink was water-damaged and soiled with a mold-like substance. These observations indicate a failure to maintain cleanliness and proper labeling, which are essential for preventing foodborne illnesses.
Plan Of Correction
Element 1: Cited Residents The facility failed to prepare food in accordance with professional standards for food service safety. No specific residents were affected by these practices. Element 2: Like Residents Residents who reside at the facility have the potential to be impacted by the identified practice. - FDS or designee will ensure that the ice scoop holder is free of debris. - FDS or designee will ensure the ice machine filter is clean and free from debris. - FDS or designee will ensure the interior of the microwave is clean and free from debris. - FDS or designee will ensure the flooring of the walk-in cooler is clean and free from debris. - FDS or designee will ensure spray bottles are appropriately labeled. - FDS or designee will ensure the floor drain cover underneath the dish machine is clean and free from debris. - FDS or designee will ensure to properly test and document the dish machine. - Housekeeping Supervisor or designee will ensure the nourishment rooms on 2nd and 3rd floor are clean and free from debris. Element 3: Education Dietary staff and Housekeeping staff will be educated on the importance of appropriate and effective methods of cleaning in all areas and the sanitation policy. Element 4: Audits The FDS or designee will complete a random audit 5 times a week for 4 weeks for cleanliness compliance. The Housekeeping Supervisor will complete a random audit 3 times a week for 4 weeks for nourishment room cleanliness. Element 5: Compliance The facility Administrator will be responsible for assuring substance compliance is attained through this plan of correction by 5/13/25 and for sustained compliance thereafter.
Deficiencies in Person-Centered Care Plans
Penalty
Summary
The facility failed to provide person-centered care plans for two residents, leading to deficiencies in addressing their specific medical and psychosocial needs. One resident, who was cognitively intact, was admitted with diagnoses including Post-Traumatic Stress Disorder (PTSD) and Vascular Dementia. However, their care plan did not include provisions for these conditions. The social worker acknowledged the absence of a care plan for these diagnoses after being questioned by the surveyor, and the Nursing Home Administrator confirmed that appropriate care plans and psych services should have been in place. Another resident, who had moderate cognitive impairment and was dependent on assistance for most activities of daily living, was observed without heel protectors despite having a pressure ulcer on the right heel. This resident often refused care and did not adhere to their Renal Diet, leading to elevated potassium and phosphorous levels. Despite these issues, there was no care plan addressing the resident's non-compliance. Interviews with staff and family confirmed the resident's frequent refusal of care and dietary non-adherence, yet the facility's Behavioral Care Services policy, which includes care plan development, was not followed.
Plan Of Correction
Element 1: It is the practice of the facility to provide person-centered interventions and care plans for patients with Vascular Dementia, PTSD, and ESRD. R78 and R46 care plans have been reviewed and updated. Element 2: Residents that have been diagnosed with Vascular Dementia, PTSD, and ESRD have the potential to be affected by this cited practice. Those residents' care plans have been reviewed and updated. Element 3: The Interdisciplinary Team reviewed the policy and procedure to Develop/Implement Comprehensive Care Plan and deemed it appropriate. The Social Services and dietician have been educated on the policy of Develop/Implement interventions and care plans with focus on to provide person-centered interventions and care plans. Element 4: S.W./Designee will audit new admissions with diagnoses of Vascular Dementia, PTSD to ensure care plans are in weekly x4 then monthly x3. Dietician/Designee will audit renal patients to ensure non-compliance diet care plans are in place and will do random audits on renal patients for compliance with diet weekly x4 weeks then monthly x3 months. Results of audits will be taken through QA for further review and recommendations. The Administrator will be responsible for sustaining compliance.
Failure to Respond to Call Lights and Provide Timely ADL Care
Penalty
Summary
The facility failed to respond to call lights and provide activities of daily living (ADL) care in a timely manner for one resident and a group of eight confidential residents. Specifically, a resident was observed waiting for over an hour to have their brief changed, with their call light out of reach on the floor. Staff entered the resident's room to deliver a breakfast tray but did not address the resident's care needs. On a follow-up visit, the resident activated their call light due to a wet brief, but multiple staff members walked by without responding. A staff member deactivated the call light without providing assistance, and the resident had to reactivate it before the Director of Nursing (DON) responded. The resident's electronic medical record indicated they were admitted with respiratory failure and COPD, had moderately impaired cognition, and were dependent on staff for toileting. Resident council meeting notes from December 2024 to March 2025 highlighted concerns about delayed ADL care and long call light wait times. A group of eight residents reported that when agency staff were on duty, call lights were often ignored, and care was delayed. The facility's policy stated that staff should respond to call lights regardless of assignment and only turn off the light once the resident's request is met.
Plan Of Correction
Element 1: Cited Residents Resident R152 currently resides in the facility. The Facility failed to respond to call lights and provide activities of daily living care in a timely manner. Element 2: Like Residents Residents who reside in the facility have the potential to be impacted by the identified deficiency. The facility completed baseline audit to ensure residents call lights are being answered in a timely manner based on resident interviews and observation. Element 3: Education Staff will be educated on the facility call light policy to ensure call lights are answered in a timely manner. Element 4: Audit Administrator or designee will complete a random audit 7x a week for 4 weeks to ensure the call lights are answered in a timely manner according to facility policy based on resident interviews and observation. Element 5: Compliance The facility Administrator will be responsible for assuring substance compliance is attained through this plan of correction by 5/13/25 and for sustained compliance thereafter.
Inappropriate Medication Administration via PEG Tube
Penalty
Summary
The facility failed to ensure the appropriate administration of medications via a percutaneous endoscopic gastrostomy (PEG) tube for a resident, identified as R73. During an observation of medication administration, an LPN was seen preparing and administering nine crushed medications through R73's PEG tube. The process involved an initial water flush of 30-40 milliliters, followed by the administration of medications with varying amounts of water flushes between them. The orders indicated a flush amount of 20-30 milliliters, but the facility's policy required a flush of 15 milliliters between medications. The LPN combined the last five medications, which was not ordered for R73, and administered them together, leading to the resident feeling full and nauseous. Interviews with facility staff, including another LPN, the Unit Manager, and the Director of Nursing (DON), revealed inconsistencies in the understanding and application of the facility's policy on PEG tube medication administration. The staff reported different practices regarding the amount of water used for flushing between medications and the combining of medications, which contradicted the facility's policy. The facility's policy required medications to be diluted with at least 30 milliliters of water and flushed with 15 milliliters of water between medications unless otherwise prescribed. This inconsistency in practice and deviation from the policy led to the deficiency in the care provided to R73.
Plan Of Correction
Element 1: It is the practice of the facility to ensure an appropriate amount of water flush is provided between administration of individual medications via peg tube. Element 2: Residents that receive medications via peg tube have the potential to be affected by this cited practice. R73 stated she was fine and that she always feels full. R73 was offered to take her medications by mouth and stated she prefers her medication via peg. LPN E was educated on medication administration via peg tube. Element 3: The Interdisciplinary Team reviewed the policy and procedure on Enteral Tube Medication Administration and deemed it to be appropriate. Nursing was educated on Enteral Tube Medication Administration. Element 4: Nurse Educator/Designee will audit random nurses weekly x4 for proper medication administration via peg, then monthly x3. Results of audits will be taken through QA for further review and recommendations. Element 5: The Administrator will be responsible for sustaining compliance.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 12.82% error rate for a resident. During a medication administration observation, an LPN prepared and administered nine crushed medications via a PEG tube for a resident. The LPN initially flushed the tube with 30 to 40 mls of water, followed by four medications with an additional 20-30 mls of water. The resident reported feeling full and nauseous, prompting the LPN to pause. The LPN then combined the remaining five medications into 30 mls of water and flushed with another 20-30 mls of water, leaving residual medication in the syringe. The LPN admitted to combining medications for some residents, although this was not ordered for the resident in question. The facility's policy requires each medication to be administered separately, diluted with at least 30 ml of water.
Plan Of Correction
Element 1: It is the practice of the facility to be free of medication error rates of 5%. Element 2: Residents that receive medications via PEG tube have the potential to be affected by this cited practice. R73 stated she was fine and that she always feels full. R73 was offered to take her medications by mouth and stated she prefers her medication via PEG. LPN E was educated on medication administration via PEG tube. Element 3: The Interdisciplinary Team reviewed the policy and procedure on medication error and deemed it to be appropriate. Nursing was educated on medication errors and medication administration via PEG. Element 4: Nurse Educator/Designee will audit random nurses weekly x4 for proper medication administration via PEG, then monthly x3. Results of audits will be taken through QA for further review and recommendations. Element 5: The Administrator will be responsible for sustaining compliance.
Failure to Administer Blood Pressure Medication as Ordered
Penalty
Summary
The facility failed to ensure the proper administration of blood pressure medication, Clonidine, for a resident as per the physician's order. During a medication pass observation, it was noted that the resident had a blood pressure of 197/96, which required the administration of Clonidine and notification to the physician as per the order. However, the previous blood pressure reading of 196/88 at 5:00 AM was not reported to the physician, and there was no documentation of this notification in the progress notes. The resident's Medication Administration Record (MAR) showed only two previous administrations of the PRN Clonidine, despite multiple instances of elevated blood pressure readings that met the criteria for administration. The resident, who was admitted with diagnoses including stroke, heart disease, chronic kidney disease, and malnutrition, had a history of moderately impaired cognition and required assistance with daily activities. The facility's failure to administer the medication as needed and to notify the physician of elevated blood pressure readings was confirmed by the Unit Manager, who acknowledged that the expectation was to follow the physician's orders and report out-of-parameter blood pressures. The resident's electronic medical record documented ten or more instances of systolic blood pressures greater than 160 since the order was initiated, indicating a pattern of non-compliance with the prescribed medication regimen.
Plan Of Correction
Element 1 It is the practice of the facility that Residents are Free of Significant Medication Errors and to ensure the PRN blood pressure medication (Clonidine) is administered as needed per physician orders. Element 2 Residents that receive PRN Clonidine have the potential to be affected by this cited practice. R73 was seen and evaluated at bedside on 4/11/25 & 4/14/25 by physician for hypertension and refusal of medication. Element 3 The Interdisciplinary Team reviewed the policy and procedure on Medication Administration and deemed it to be appropriate. Nursing was educated on PRN blood pressure medication administration and to recheck blood pressure within 1 hour. If SBP is greater than 160 to call the physician. Element 4 UM/Designee will audit residents who have PRN blood pressure medication to ensure they are given appropriately weekly x4 then monthly x3. Results of audits will be taken through QA for further review and recommendations. Element 5 The Administrator will be responsible for sustaining compliance.
Failure to Properly Label and Discard Expired Medications
Penalty
Summary
The facility failed to properly label and discard expired drugs and biologicals in accordance with accepted professional principles. During observations, it was noted that several medication carts and a medication room contained items that were either expired or lacked proper labeling. Specifically, a dorzolamide eye drop vial was found without a resident identifier or date opened, glucose strips were not dated when opened, and insulin aspart vials were expired. Additionally, a Basalgar insulin pen, Trelegy inhalers, and an Arnuity inhaler were not dated when opened, and some lacked resident identifiers. Further observations revealed that a tuberculin vial in a medication room was open but not dated, and Latanoprost eye drops and Prednisone Acetate bottles were found without identifying labels or open dates. The Director of Nursing confirmed that expired medications should be discarded and that medications requiring them should have a date opened and an identifier. The facility's Prescription Dating/Storage Guidelines and manufacturer's information were reviewed, highlighting the specific storage and expiration requirements for these medications.
Plan Of Correction
Element 1: It is the practice of the facility to ensure proper labeling of drugs and biologicals. The glucose strips, insulins, and inhalers that were not dated and that did not have patient identifiers on them were removed from the med carts and discarded. Element 2: Residents who have eye drops, insulins, and inhalers have the potential to be affected by this cited practice. Those residents' inhalers, insulins, and eye drops—the medication carts were checked for proper label and dating. No other issues were found. Element 3: The Interdisciplinary Team reviewed the policy and procedure titled: Storage and Expiration Dating of Medications/Biologicals, and deemed it appropriate. The nurses and Nurse Managers were inserviced on the proper labeling and dating of medications and biologicals. Element 4: U.M./or designee will audit all medication carts weekly for 4 weeks to ensure eye drops, inhalers, and insulins are properly labeled and dated as needed, then monthly for 3 months. Results of audits will be taken through QA for further review and recommendations. The Administrator will be responsible for sustaining compliance.
Inadequate Sanitation of Tube Feeding Equipment
Penalty
Summary
The facility failed to maintain a tube feeding pole in a sanitary manner for a resident who was dependent on enteral feeding due to severe cognitive impairment and medical conditions including Hemiplegia, Hemiparesis, Dysphagia, and Diabetes. Observations revealed that the tube feeding pole and base had a thick layer of brown dried tube feed stuck to it, and a bag of Isosource 1.5 cal was missing the resident's name, date, time, or order. Additionally, used gloves were found on the floor, and a pool of wet fluid was observed on the floor. The Infection Control Preventionist stated that the expectation was for the pole to be cleaned when soiled, but this was not adhered to, as evidenced by multiple observations of the soiled pole over several days. The facility's policy on cleaning and disinfection of resident-care equipment was not followed, as the tube feeding equipment was not stored in the soiled utility room as required.
Plan Of Correction
Element 1 It is the practice of the facility to ensure appropriate infection control practices are used for equipment cleaning. The Nursing and Housekeeping staff were educated on cleaning of the tube feed pole and spills on the floor. Element 2 Residents that have a peg tube pole in the facility have the potential to be affected by this cited practice. Residents' rooms with a tube feeding pole were audited and cleaned. Element 3 The Interdisciplinary Team reviewed the policy and procedure titled: Cleaning and Disinfection of Resident-Care Equipment was reviewed and deemed the policies to be appropriate. Nursing and Housekeeping will continue to be educated on this policy. Element 4 Environmental Manager/designee will randomly audit on residents with tube feeding poles to ensure there are no spills on the floor or pole itself for 4 weeks and then monthly x 3 months. Results of audits will be taken through QA for further review and recommendations. The Administrator will be responsible for sustaining compliance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were accessible to residents, as observed in the cases of three residents. For one resident, the call light was found on the floor by the side of the bed, out of reach, on two separate occasions. This resident, who had intact cognition but required substantial assistance for activities of daily living (ADLs), was unaware of the call light's location. Another resident's call light was observed on the floor under the bed and later next to the bed, both times out of reach. This resident had moderately impaired cognition and required moderate assistance for ADLs. A Licensed Practical Nurse (LPN) was observed picking up the call light from the floor and clipping it to the resident, indicating a lack of consistent adherence to call light placement protocols. A third resident's call light was also found on the floor by the bed, out of reach. This resident had moderately impaired cognition, was frequently incontinent of urine, and was dependent on staff for toileting. The facility's policy on call light accessibility, issued in August 2023, mandates that staff ensure call lights are within reach of residents. However, interviews with staff and the Nursing Home Administrator (NHA) revealed that the expectation for call light placement was not consistently met, as evidenced by the observations made during the survey.
Plan Of Correction
Residents R57, R106, and R152 currently reside in the facility. The facility failed to ensure that call lights are in reach. Element 2: Like Residents Residents who reside in the facility have the potential to be impacted by the identified deficiency. The facility completed a baseline audit to ensure residents had call lights in place. Element 3: Education Staff will be educated on the importance of ensuring the call lights are within reach for residents. Element 4: Audit An administrator or designee will complete a random audit on 10 residents a week for 4 weeks to ensure their call light is in place. Element 5: Compliance The facility Administrator will be responsible for assuring substance compliance is attained through this plan of correction by 5/13/25 and for sustained compliance thereafter.
Failure to Develop and Implement Required Care Plans for Diagnoses and Non-Compliance
Penalty
Summary
A review of one resident's medical record revealed that, despite diagnoses of Post-Traumatic Stress Disorder (PTSD) and Vascular Dementia, there was no care plan in place addressing these conditions. The resident was cognitively intact and required assistance with activities of daily living. When questioned, the social worker confirmed the absence of care plans for these diagnoses, and the nursing home administrator acknowledged that appropriate care plans should be in place for such conditions. Another resident, who was dependent for all activities of daily living except eating and had a history of encephalopathy, diabetes with neuropathy, kidney disease requiring dialysis, and a pressure ulcer, was observed not using prescribed heel protectors and was known to frequently refuse care, including dietary restrictions. Multiple staff interviews confirmed the resident's pattern of non-compliance, yet there was no care plan addressing this behavior. The facility's own policy requires care plan development and implementation based on comprehensive assessment, which was not followed in these cases.
Call Light Not Accessible to Resident with Impaired Cognition and Mobility
Penalty
Summary
On two separate occasions, a resident's call light was observed to be on the floor and out of the resident's reach, first under the bed and later next to the bed. During one of these observations, an LPN entered the room and was questioned about the proper placement of the call light, at which point the LPN picked up the call light and clipped it to the resident. Another LPN confirmed in an interview that the expectation is for the call light to be clipped to or located beside the resident within their reach. The resident involved had a history of respiratory failure and muscle weakness, with moderately impaired cognition and required moderate to total assistance for all activities of daily living except eating, as documented in the most recent MDS assessment.
Call Light Inaccessible to Dependent Resident
Penalty
Summary
A call light was observed on the floor by the bed, out of reach of a resident who had been admitted with respiratory failure and COPD. The resident's most recent MDS indicated moderately impaired cognition, frequent urinary incontinence, and dependence on staff for toileting. Facility policy requires staff to ensure call lights are accessible to residents at bedside, and the administrator confirmed that staff are expected to check call light placement and accessibility for all residents. Despite these requirements, the call light was not within the resident's reach at the time of observation.
Failure to Maintain Delayed-Egress Door Alarms and Locking Systems
Penalty
Summary
Surveyors observed that several emergency exit egress doors, specifically those leading to stairways on the 2nd and 3rd floors, were signed as having a 15-second delay with an alarm to sound upon opening. However, when these doors were tested, they opened freely without any resistance or alarm activation. This was confirmed during observations at multiple locations and times within the facility. The lack of functioning delayed-egress locking systems and alarms on these doors means that the doors did not operate as indicated by their signage. The facility failed to ensure that doors in a required means of egress were equipped and maintained in accordance with the special locking arrangements for clinical needs, as required by regulation. These findings were confirmed with the facility Maintenance Director at the time of observation.
Plan Of Correction
K222 Egress Doors 1. The facility failed to ensure doors in a required means of egress are not equipped with a latch or lock that requires the use of a tool or key from the egress unless meeting the special locking arrangements for clinical needs in accordance with 19.2.2.2.5.1 and 19.2.2.2.6. a. Emergency exit to egress door to Stairway "A" 3rd floor was assessed and serviced. b. Emergency exit egress door on 3rd floor by sitting was assessed and serviced. c. Emergency exit egress door to stairway "A" 2nd floor was assessed and serviced. 2. The maintenance director and staff will be educated on checking and maintaining any breaches in egress doors with a latch or lock throughout the facility. 3. To ensure continued compliance is maintained with the emergency fire exits, the Maintenance Director/designee will complete random audits 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Inoperative Exit Signage and Noncompliance with Emergency Lighting Requirements
Penalty
Summary
The facility failed to ensure that exit and directional signs were displayed in accordance with regulatory requirements, specifically 7.10 and 19.2.10.1, which mandate continuous illumination and connection to the emergency lighting system. During observations on April 14, 2025, multiple ceiling-mounted exit signs were found to be inoperative: one on the 3rd floor Lakeland Hall by stairway "C," several in the 3rd floor corridor at the Jefferson Central Stairway door and the remainder of the 3rd floor, and one on the 2nd floor Jefferson Hall. These deficiencies were confirmed by the facility Maintenance Director at the time of observation. All 175 residents in the facility could be affected by the lack of properly functioning exit signage in the event of a fire, as the required continuous illumination and emergency lighting backup were not provided for these exit signs.
Plan Of Correction
K293 - Exit Sign 1. The Facility failed to ensure exit and directional signs are displayed in accordance with 7.10, continuously illuminated and served by the emergency lighting system as required by 19.2.10.1. a. Ceiling mounted exit sign 3rd floor Lakeland Hall by stairway "C" is now operative. b. Ceiling mounted exit signs 3rd floor in the corridor at Jefferson Central Stairway door and the remainder of the 3rd floor are now operative. c. Ceiling mounted exit sign 2nd Floor Jefferson Hall is now operative. 2. The maintenance director and staff will be educated on the importance of exit signs/emergency lighting to be continuously activated and working properly. 3. To ensure continued compliance is maintained with the exit sign lighting/emergency lighting, the Maintenance Director/Designee will complete random audits 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Failure to Maintain Required Range Hood Suppression System Inspections
Penalty
Summary
The facility failed to ensure that its cooking facilities were protected in accordance with NFPA 96 standards. Specifically, there was no evidence provided of the required semi-annual service dates for the installed range hood suppression system from 2023 to the present, with the last recorded service date being 2/15/2023. Additionally, the facility did not provide documentation of the required owner's monthly hood suppression system inspections for 2024 to the present. These deficiencies were confirmed during record review with the Maintenance Director and no supporting compliance documentation was presented to the surveyor by the time of exit. All 175 residents in the facility could be affected by these lapses in fire protection system maintenance, as identified during the survey process.
Plan Of Correction
K324 - Cooking Facilities 1. The facility failed to ensure cooking facilities are protected in accordance with NFPA 96. a. The facility conducted monthly hood suppression system inspections for the range hood with proper documentation. b. The facility conducted semi-annual service for the installed range hood suppression system with proper documentation. 2. The Maintenance Director and Food Service Director were educated on the importance of monthly and semi-annual testing and the proper documentation to maintain compliance. 3. To ensure continued compliance of the Hood Suppression System is maintained, the Maintenance Director/Designee will report monthly and semi-annually. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program that complies with NFPA 70 and NFPA 72. During an observation, the fire alarm remote panel located in the vestibule to Physical Therapy (new) was found to be displaying incorrect date and time information, specifically showing '0506 on 06/03/2059.' This issue was confirmed by the facility Maintenance Director at the time of observation. This deficiency could potentially affect all 175 residents in the facility in the event of a fire situation, as the fire alarm system may not function as required due to improper maintenance or testing.
Plan Of Correction
K345- Fire Alarm System- Maintenance and Testing 1. The facility failed to ensure the fire alarm system was tested and maintained in accordance with an approved program complying with NFPA 70 and NFPA 72. a. The Fire alarm remote panel date and time in the vestibule to Physical Therapy is correct. 2. The Maintenance director and staff will be educated on the importance of rounding and ensuring the time and date on the fire alarm remote panels have the correct date and time. 3. To ensure compliance is maintained, the Maintenance Director/designee will complete a random audit 3x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Deficient Sprinkler System Maintenance and Testing
Penalty
Summary
The facility failed to maintain and test its automatic sprinkler and standpipe systems in accordance with NFPA 25 requirements. Observations on multiple occasions revealed several deficiencies, including ceiling tile penetrations in the IT/Telecom Room and storage room, missing ceiling tiles in the Maintenance Office and laundry area, and missing or incomplete sprinkler components such as escutcheon rings and concealed covers in various rooms including a resident bathroom, Dietary Rest Room, Dialysis Treatment Room, and Conference Room. Additionally, dirty sprinkler heads were found behind the dryers in the laundry, and stock items were stored within 18 inches of a sprinkler head in the vestibule for dialysis storage. These issues were confirmed by the Maintenance Director during the survey. Further review of facility records showed a lack of documentation for the required quarterly flow tests for the automatic fire suppression system for two consecutive quarters. No evidence of these tests was provided to the surveyor by the time of exit. The combination of physical deficiencies and missing compliance documentation affected all 175 residents in the facility, as confirmed through interviews and record reviews with the Maintenance Director.
Plan Of Correction
K353 - Sprinkler System Maintenance and Testing 1. The facility failed to provide sprinkler system maintenance and testing as required by NFPA 25. a. The ceiling tile penetration on 2nd floor new side by IT/Telecom room has been replaced. b. The ceiling penetration in 2nd floor storage room with roof access has been replaced. c. Escutcheon plate in the 2nd floor room #235 has been replaced. d. The ceiling tile penetration in Maintenance Office by the IT equipment rack has been replaced. e. Dirty sprinkler heads behind the dryers have been cleaned. f. Missing sprinkler head in the Dietary restroom has been replaced. g. Escutcheon plate in the Dialysis den has been replaced. h. Missing sprinkler in the 1st floor conference room has been replaced. i. All combustibles and stock items within 18" have been removed from dialysis storage room. j. Missing ceiling tile above the washers in the laundry room has been replaced. 2. The maintenance director and staff will be educated on the importance of routine rounding to ensure the sprinkler heads have escutcheon plates and are clean, ceiling tiles maintain no breaches, and combustible/stock items maintain 18" from the ceiling. 3. To ensure continued compliance, the Maintenance director/designee will complete random audits 5 times a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Improper Storage of Combustibles and Electrical Panel Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's compliance with NFPA 54 and NFPA 70 standards for gas and electrical equipment. Specifically, combustible stock items were found stored within three feet of electrical panels in both the Physical Therapy storage area and the first floor mechanical room. Additionally, the electrical panel in the second floor electrical closet near Room #263 was found with its cover disassembled and resting on the floor. Two open blanks were identified in the electrical panel for the first floor auxiliary kitchen located in the first floor mechanical room. Furthermore, combustible items were stored on top of and within three feet of a transformer in the first floor mechanical room. These findings were confirmed by the facility Maintenance Director at the time of observation. All 175 residents of the facility could be affected by these deficiencies, as the improper storage of combustibles and unsecured electrical panels present a risk in the event of a fire caused by electrical sparks, arcing, or overheating.
Plan Of Correction
K511 – Utility's-Gas and Electric 1. The facility failed to ensure equipment using gas or gas related piping complies with NFPA 54 and electrical wiring and equipment complies with NFPA 70. a. The combustible stock items stored within 3' of the electrical panels in the Physical Therapy Storage have been removed. b. The electrical panel in the 2nd floor electrical closet by room #263 has been reassembled. c. The Electrical Panel for the 1st floor auxiliary kitchen in the 1st floor mechanical room with 2 open blanks has been corrected. d. The combustibles stored within 3' of the electrical panel in the 1st floor mechanical room have been removed. e. The combustibles stored on top of the transformer in the 1st floor mechanical room have been removed. 2. The maintenance director and staff will be educated on maintaining clearance of 3' of electrical panels and transformers, and the panels are properly assembled and maintained within the requirements of NFPA 54 and 70. 3. To ensure compliance is maintained, the maintenance director/designee will complete a random audit 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Failure to Provide Timely Fire Damper Inspection Documentation
Penalty
Summary
The facility failed to provide evidence of the required quadrennial (every four years) servicing and inspection of their installed fire dampers, as mandated by regulatory standards. During a record review on April 15, 2025, it was found that the last recorded servicing of the fire dampers was dated June 16, 2020, and no documentation supporting compliance with the current inspection requirement was available for review. This deficiency was confirmed with the facility Maintenance Director at the time of the record review. The lack of current inspection documentation could affect all 175 residents in the event of a fire, as noted in the findings.
Plan Of Correction
K521 - HVAC 1. The facility failed to ensure heating, ventilation, and air conditioning in compliance with 9.2. a. The facility scheduled the required quadrennial serving and inspection of the installed Fire Dampers. 2. The Maintenance Director was educated on the required quadrennial serving and inspection of the installed fire dampers and proper documentation following required fire drills. 3. To ensure compliance is maintained, the Maintenance Director/designee will complete an audit monthly following each fire drill with proper documentation. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Failure to Train Staff on Emergency Evacuation Procedures
Penalty
Summary
The facility failed to ensure that there was a written plan for the protection and evacuation of all residents in the event of an emergency, as required by regulatory standards. During an interview, nursing staff on the second floor reported that they had not received periodic training on procedures for removing residents from elevated floors to the ground level if elevators were not operable or during a fire situation. This lack of training was confirmed by the Maintenance Director at the time of observation. The deficiency was identified through direct questioning of staff and was based on their statements regarding the absence of such training since their employment at the facility. No specific residents or their medical conditions were mentioned in the report, and the findings were based solely on staff interviews and confirmation by facility leadership.
Plan Of Correction
K711 - Evacuation and Relocation Plan. 1. The facility failed to ensure there is a written plan for the protection of all residents and for their evacuation in the event of an emergency, employees are periodically instructed in their duties under the plan as required by 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3. a. The facility will schedule annual education and drill for the evacuation of residents from elevated floors to the ground level. 2. The Administrator/safety committee will be educated on the importance of routinely educating and scheduling drills of the evacuation of residents from elevated levels to the ground. 3. To ensure compliance is maintained, the Administrator will complete audits monthly to ensure staff are educated on the evacuation of residents from elevated levels. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Failure to Conduct Fire Drills at Unexpected Times
Penalty
Summary
The facility failed to conduct fire drills as required by regulations 19.7.1.4 through 19.7.1.7. Specifically, record review showed that fire drills for both the 1st and 2nd shifts from the 2nd quarter of 2024 to the present were consistently held at similar, expected times, rather than at unexpected times under varying conditions as required. The times for the 1st shift drills were all around midday, and the 2nd shift drills were all in the mid-afternoon. This pattern was confirmed during an interview with the Maintenance Director at the time of record review. The deficiency could potentially affect all 175 residents in the facility in the event of a fire situation.
Plan Of Correction
K712- Fire Drills 1. The facility failed to conduct fire drills as required by 19.7.1.4 through 19.7.1.7. a. The facility conducted a fire drill at an unexpected time and under varying conditions from the previous month/quarter. 2. The Maintenance Director was educated on the importance of running fire drills at unexpected times and under varying conditions from previous drills. 3. To ensure substantial compliance, the Administrator will do an audit of fire drills monthly for the 6 months. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Deficient Emergency Generator Maintenance and Documentation
Penalty
Summary
The facility failed to maintain compliance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 requirements for emergency electrical systems. During observation, both of the facility's emergency backup power generators were found with unsecured access panels, lacking the required handle locks or other devices to prevent unauthorized access. This was confirmed by the Maintenance Director at the time of observation. Additionally, the facility was unable to provide documentation of the required annual servicing date and annual 90-minute load bank test for the emergency generator set, despite the generator's initial service date being recorded. Further record review revealed that the facility did not have evidence of the required monthly load tests for the generator set from February 2024 onward. The facility also failed to provide documentation of the annual fuel analysis for the stored diesel fuel used by the emergency backup power generators. No compliance documentation was presented to the surveyor by the time of exit, and these findings were confirmed with the Maintenance Director during the record review process.
Plan Of Correction
K918 – Electrical Systems- Essential 1. The facility failed to ensure generators or other alternative power sources are in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70. a. The installed emergency backup power generators were supplied with lock/denying devices. b. The new emergency back-up power generator has had its annual 90-minute load back test and inspection scheduled. c. The monthly load run test and inspection has been performed and documented on the new generator. d. The annual fuel analysis for the stored diesel fuel for the emergency back-up power generator has been completed. 2. The maintenance director and staff were educated on weekly, monthly, and annually required generator tests as well as proper documentation according to NFPA standards. 3. To maintain continued compliance, the Maintenance Director or designee will complete a random audit week for 4 weeks to ensure the NFPA standards are being met. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Inoperative Stairway Path Interrupter on 2nd Floor Egress
Penalty
Summary
During an observation on April 14, 2025, it was found that the electronic stairway path interrupter installed on the 2nd floor stairway path of egress by the elevators was inoperative. This device is intended to guide occupants to the proper egress level during emergencies. The inoperative condition could result in individuals evacuating to the lower level and missing the correct exit during a fire or emergency event with diminished visibility. The deficiency was confirmed at the time of observation with the facility Maintenance Director. A total of 58 out of 175 residents could be affected by this issue in the event of a fire situation, as noted in the findings.
Plan Of Correction
K225- Stairways and Smoke Proof Enclosures 1. The facility has failed to ensure stairways and smokeproof enclosures used as exits are in accordance with 7.2, as required by 19.2.2.3 and 19.2.2.4. 2. The electronic stairway path interrupter installed on the 2nd floor stairway path of egress by the elevators is operative. 3. The maintenance director and staff will be educated on the importance of egress doors/gates being continuously activated and working properly. 4. To ensure continued compliance is maintained with the stairway path interrupter, the Maintenance Director/Designee will complete random audits 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 5. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Obstructed Fire Extinguisher in Physical Therapy Charting Room
Penalty
Summary
A deficiency was identified when, during an observation in the Physical Therapy Charting Room, a fire extinguisher located by the counter was found to be obstructed by combustible stock items. This situation was observed on April 14, 2025, at 12:25 PM and was confirmed through an interview with the facility Maintenance Director at the time of the observation. The report notes that this failure to ensure the fire extinguisher was accessible and properly maintained was not in accordance with NFPA 10 standards for portable fire extinguishers. The deficiency had the potential to affect 28 of 175 residents in the event of a fire.
Plan Of Correction
K355 - Portable Fire Extinguishers 1. The facility failed to ensure portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10. a. Fire Extinguisher by the counter in the Physical Therapy Charting Room is clear of combustible stock items. 2. Maintenance Director and Staff will be educated on the importance of keeping fire extinguishers free from obstruction and clear of combustible stock items. 3. To ensure continued compliance, the Maintenance director/designee will complete random audits 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Smoke Barrier Doors Failed to Latch and Lacked Self-Closure Devices
Penalty
Summary
Surveyors observed that several smoke barrier doors within the facility did not meet Life Safety Code (LSC) requirements. Specifically, the fire-rated cross corridor door at the 2nd floor storage room with roof access, the fire-rated double door set to Physical Therapy, and the door to the 2nd floor sitting room all failed to positively latch when tested. Additionally, the doors to the Physical Therapy storage area lacked required self-closure devices. These deficiencies were confirmed during the survey through direct observation and interview with the facility Maintenance Director. A total of 58 out of 175 residents could be affected by these issues in the event of a fire, as the doors in question are intended to serve as smoke barriers but did not function as required at the time of inspection.
Plan Of Correction
K374 - Subdivision of Building Spaces - Smoke Barrier 1. The facility failed to ensure smoke barriers doors meet the requirements of the LSC. a. Self-closers have been added to the Physical Therapy Storage doors. b. The fire-rated cross corridor door at the 2nd floor storage room with roof access has been repaired. c. The 2nd Floor Sitting Room door latch has been repaired. d. The latch to Physical Therapy double doors has been repaired. 2. The maintenance director and staff will be educated on the importance of the LSC requirements of various doors in the facility latch properly. 3. To ensure compliance is maintained, the maintenance director/designees will complete random audits 3x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Improper Storage of Oxygen Cylinders Near Combustibles
Penalty
Summary
Oxygen cylinders were observed stored within five feet of combustible stock items in the second floor clean linen room. This storage arrangement does not comply with NFPA 99 requirements, which mandate that oxidizing gases such as oxygen must be separated from combustibles by at least 20 feet, or 5 feet if the area is sprinklered, or stored in a compliant cabinet. The cylinders were not properly segregated from combustible materials, as required by the standard. The deficiency was identified during an observation conducted on April 14, 2025, at 10:35 AM, and was confirmed by the facility Maintenance Director at the time of the survey. The report notes that this practice could affect 76 of 175 facility residents in the event of a fire emergency, but does not provide specific details about individual residents' medical histories or conditions at the time of the deficiency.
Plan Of Correction
K923 – Gas Equipment- Cylinder and Container Storage. 1. The facility failed to ensure storage of nonflammable gasses meet all requirements of NFPA 99. a. Oxygen cylinders within 5' was cleared of combustible stock items on the 2nd floor of new side clean linen room. 2. Maintenance Director and staff were educated on the proper Oxygen cylinder storage requirements. 3. To ensure continued compliance, Maintenance Director/designee will complete random audits 5x a week for 4 weeks to ensure oxygen rooms and linen closets have proper storage of oxygen cylinders. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to protect a resident during an abuse investigation, resulting in fear of retaliation and feeling scared. The incident involved a staff member, Staff A, who was alleged to have misappropriated funds from a resident's bank account. The resident, R901, had opened a bank account with Staff A as a secondary account holder. Over time, R901 noticed unauthorized withdrawals and gambling transactions linked to the account, leading to a total unauthorized withdrawal of $18,364.14. Despite the resident's attempts to address the issue, Staff A continued to have access to the account until it was closed. The situation escalated when the police were involved, and Staff A was instructed not to have contact with the resident. However, the following day, Staff A entered the resident's room, confronting them aggressively and causing the resident to feel threatened and scared. The resident was unable to call for help as their phone was out of reach. Staff A's actions included leaving multiple voicemails and text messages, further intimidating the resident. The facility's failure to protect the resident during the investigation is evident in the lack of immediate removal of Staff A from the premises and the inability to prevent further contact with the resident. The facility's policy on abuse prevention was not effectively implemented, as Staff A was able to confront the resident despite being suspended. This oversight led to the resident experiencing significant emotional distress and fear for their safety.
Plan Of Correction
Element 1: Cited Residents R901 no longer resides in the facility. The facility failed to protect one resident during an abuse investigation resulting in fear of retaliation and feeling scared. Element 2: Like Residents Residents who reside in the facility have the potential to be impacted by the identified practice. The facility completed an initial baseline audit to ensure that residents feel protected in the facility. Element 3: Education Staff will be educated on the facility abuse policy and process to ensure that residents are protected and free from abuse. Element 4: Audits Administrator or designee will complete 10 random audits x4 weeks to ensure that residents feel safe in this facility has no fear of retaliation. Element 5: Compliance The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 3/21/2025 and for sustained compliance thereafter.
Staff Misappropriation of Resident Funds
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's funds by a staff member, resulting in unauthorized withdrawals totaling $18,368. The incident involved a resident who had opened a joint bank account with a staff member, Staff A, after expressing frustration with their family's delay in assisting them. The account was opened with the resident as the primary account holder and Staff A as the secondary. Over time, the resident noticed declined transactions despite having funds in the account, leading them to discover unauthorized withdrawals linked to a gambling app used by Staff A. The resident reported the issue to their family, who then accompanied them to the bank to close the account and file a police report. The police instructed the resident to call 911 if Staff A approached them. Despite being suspended, Staff A confronted the resident aggressively, causing the resident to fear for their safety. Staff A also made multiple phone calls to the resident, leaving messages that further intimidated the resident. The facility's investigation revealed that Staff A had used the resident's account for personal gambling activities and claimed to have reimbursed some of the funds. However, the total amount taken was significantly higher than what was returned. The facility's policy on abuse and misappropriation of resident property was not effectively implemented, as the incident was not detected or prevented in a timely manner, leading to significant financial and emotional distress for the resident.
Plan Of Correction
Element 1: Cited Residents Resident R901 no longer resides in the center. The facility failed to prevent staff misappropriation of resident funds. The facility initiated immediate suspension and investigation of employee. Element 2: Like Residents Residents residing in the facility have the potential to be impacted by the identified practice. The facility completed an initial baseline audit to ensure residents' funds are protected. Element 3: Education Staff will be educated on resident rights with a focus on misappropriation and the abuse policy. Element 4: Audits Administrator or designee will complete random audits on 10 residents a week for 4 weeks to ensure residents are free from misappropriation/exploitation. Administrator or designee will complete random audits on 5 employees a week for 3 weeks to ensure staff have knowledge and understanding of the abuse policy. Element 5: Compliance The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 3/21/2025 and for sustained compliance thereafter.
Failure to Notify Residents of Room Changes
Penalty
Summary
The facility failed to provide proper notification of room changes for two residents, R906 and R908, as required by their policy. R906's responsible party was not informed of the room change until two days after it occurred, and there was no documentation in the electronic medical record indicating prior notification. R906, who has diagnoses including dementia and severely impaired cognition, was moved to a room with a resident who frequently yelled, causing disturbance. The responsible party had to inquire about the new room location upon visiting, highlighting a lack of communication from the facility. Similarly, R908 was informed of their room change just before it happened, without the opportunity to preview the new room, which was smaller. The move was necessitated by the need to accommodate a COVID patient, but there was no documentation of prior notification to R908 or their family. R908, who has intact cognition and diagnoses including dementia and pulmonary disease, expressed dissatisfaction with the new room. The facility's policy requires written notice and discussion of room changes with residents or their representatives, which was not adhered to in these cases.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to implement care planned interventions to prevent a fall for a resident with a history of falls and medical conditions including Spina Bifida with Hydrocephalus, Paraplegia, and Epilepsy. The resident's care plan included an intervention to place an anti-slip pad in the wheelchair seat to mitigate fall risk. However, during an incident, the resident was left unattended sitting on a mechanical lift sling in the wheelchair, which was not in accordance with the care plan or facility expectations. On the day of the incident, a CNA was preparing to transfer the resident from the wheelchair to the bed using a mechanical lift. The CNA placed a sling under the resident but realized it was the wrong size and left to retrieve the correct one. During this time, the resident slid forward out of the wheelchair and fell to the floor. The LPN assessed the resident for injuries and arranged for hospital transfer for further assessment. The facility's Director of Nursing acknowledged that the resident should not have been left unattended on the sling, and the facility lacked specific policy documentation addressing this issue.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to perform transfers according to the plan of care for a resident with severe cognitive impairment and a history of chronic shoulder dislocations. The resident was admitted with diagnoses including developmental disorder of scholastic skills and unspecified dislocation of the left shoulder joint. The care plan specified that the resident should be transferred using a mechanical lift with the assistance of two people. However, staff used a sit to stand lift instead, which was not in accordance with the care plan. An incident occurred when a CNA observed a lump on the resident's left shoulder, indicating a dislocation, which was confirmed by an x-ray. The Director of Nursing reported that staff had been using the incorrect lift method due to not reviewing the Kardex, which contained the correct transfer instructions. This improper transfer method was identified as the root cause of the shoulder dislocation during a meeting of the facility's Interdisciplinary Team.
Failure to Provide Scheduled Grooming and Showering
Penalty
Summary
The facility failed to provide grooming and showers according to schedule and preference for two residents, leading to a deficiency in the care provided for Activities of Daily Living (ADLs). Resident R701, who was admitted with diagnoses of Generalized Anxiety Disorder and Depression, had an intact cognition with a Brief Interview for Mental Status (BIMS) score of 15/15. Despite being dependent on staff for bed mobility and transfers, R701 only received bed baths during their stay, with no showers documented. The Director of Nursing (DON) acknowledged that if bed baths were R701's preference, it should have been documented in the care plan and progress notes, which was not the case. Resident R714, who was admitted after hospitalization for Epididymitis, had a fluctuating BIMS score indicating severely to moderately impaired cognition. R714 was observed with long facial hair and expressed difficulty in shaving, stating that facility staff did not have time to assist. The facility records indicated a care plan for ADL self-care deficit, requiring assistance with personal hygiene, including shaving. However, the resident's request for help was not adequately addressed, leading to the deficiency in providing necessary grooming assistance.
Failure to Schedule Follow-Up Appointment for Resident with Catheter
Penalty
Summary
The facility failed to arrange a follow-up appointment for a resident who required a urology consultation after being discharged from the hospital with an indwelling catheter. The resident, who had an intact cognition and required assistance with mobility and transfers, was observed with a catheter drainage bag attached to their wheelchair. The resident reported that the catheter was initially removed but had to be reinserted due to a high bladder scan result. The hospital discharge paperwork indicated a need for a neurology follow-up within 5-7 days, which was not scheduled by the facility. The Director of Nursing and the Unit Clerk both acknowledged attempts to schedule the appointment, but they were unsuccessful in receiving a callback from the urology office. The Unit Clerk mentioned informing the floor nurses about the situation, but there was no documentation in the progress notes regarding the appointment or notification to the physician. The facility's policy on consultations requires scheduling appointments for external consultations, which was not adhered to in this case.
Failure to Serve Palatable and Properly Heated Meals
Penalty
Summary
The facility failed to provide palatable and appropriately heated meals to residents, as evidenced by observations and interviews with four residents. Residents reported receiving cold or barely warm food, with one resident specifically mentioning cold eggs and another describing the food as awful and never hot. During an observation of the food service, meals were noted to be left uncovered on a steam table for several minutes before being served, which could contribute to the food cooling down. Additionally, a test tray revealed that while the coffee was very hot, the food was only very warm and not hot, with the pork medallion dish being extremely salty and the vegetables tasteless and inedible. The facility's Tray Delivery Schedule indicated that lunch trays were to be delivered between 11:00 AM and 12:30 PM, with the last unit receiving trays by 12:30 PM. However, the test tray for the last unit was received at 1:40 PM, indicating a delay in the delivery schedule. The Dietary Manager confirmed that food temperatures were checked before plating and were within limits, but could not explain why trays were delayed on the day of the survey. This discrepancy between the scheduled and actual delivery times, along with the residents' complaints and the test tray findings, highlight the facility's failure to ensure meals were served at a safe and appetizing temperature.
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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