The Lakeland Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Southfield, Michigan.
- Location
- 26900 Franklin Road, Southfield, Michigan 48034
- CMS Provider Number
- 235589
- Inspections on file
- 32
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at The Lakeland Center during CMS and state inspections, most recent first.
Surveyors found that nursing staff did not receive required annual skills competency evaluations, as five CNAs had competency dates showing lapses beyond the facility’s policy requirement for yearly re-validation. The staff development nurse, who also serves as the Infection Preventionist, confirmed that competencies were checked at hire but stated they were unaware that annual evaluations were required, despite a written policy mandating orientation, annual re-validation, and as-needed skills evaluations.
Surveyors identified widespread failures to maintain a clean, safe, and homelike environment, including shower beds with urine‑smelling liquid in soiled liners, dirty and deteriorated shower rooms, and resident rooms with debris, food crumbs, stains, and discarded linens on the floor. Hallways and common areas had strong urine and bowel movement odors, sticky and soiled flooring, heavily soiled and peeling wallpaper, and damaged handrails with exposed sharp edges. A housekeeping closet containing chemicals was found unlocked and unattended, and a shower bed had a broken pin for a rail that had not been reported. Multiple residents reported infrequent room cleaning, persistent unpleasant odors, and dissatisfaction with housekeeping, while facility policies required a clean, sanitary environment, prompt reporting of environmental concerns, and safe chemical storage.
The facility failed to provide and document adequate ADL care, including bathing, personal hygiene, and nail care, for several dependent residents. One resident reported missed bed baths and long waits for assistance, which was supported by gaps in CNA bath documentation. Another resident with severe cognitive impairment and hand contractures was observed in the same gown with foul body and hand odor and long, debris‑filled nails, with only one shower documented in the prior month. A resident with vascular dementia and hemiparesis had family complaints of delayed personal care, remaining in bed undressed, and strong urine odor from the bed, while records showed only one shower in 30 days despite care plan interventions. A cognitively intact resident dependent on staff for bathing reported sometimes receiving only a bed bath or no shower when staffing was low, and documentation showed only three showers in 30 days with no refusals. The DON stated CNAs were to document all bathing in the EMR, and the facility’s ADL policy required services to maintain grooming and personal hygiene.
The facility failed to maintain sufficient licensed nurses and CNAs to meet residents’ ADL needs, as evidenced by staffing patterns that did not match the facility assessment and policy, frequent call‑offs, and unfilled assignments. A resident reported going an entire shift without incontinence care and missing scheduled bed baths, while another missed therapy sessions because staff could not get them ready. A resident described a roommate repeatedly left in bed despite family requests, long waits over 30 minutes for assistance, missed showers, and a weekend when residents were not gotten out of bed and meals were served in rooms. Other residents and council participants reported only one CNA covering large areas, long call‑light response times, being left in bed until early afternoon or for entire weekends, and being forced to accept showers at non‑preferred times. A CNA confirmed that on a short‑staffed weekend, multiple call‑offs occurred, management did not assist, and tasks could not be completed.
Surveyors observed multiple medication administration errors resulting in a 19% error rate. One resident received incorrect doses of magnesium oxide and folic acid, had a gabapentin capsule crushed instead of opened, and did not receive an ordered dose of famotidine. Another resident was given a sennosides tablet instead of the ordered Senna-S combination product. Staff interviews and policy review confirmed that medications were not administered in accordance with the facility’s own medication administration standards and the rights of medication administration.
The facility failed to support resident self-determination and choice for two residents. One resident, who had previously used a wheelchair seatbelt and could unbuckle it independently, repeatedly requested a seatbelt on a new wheelchair but reported being told by staff that the State did not allow it, and the request was not acted upon. Another resident, with frequent hospitalizations, consistently refused OT services from a specific COTA, documented a concern requesting a different OT, and stated willingness to work with another therapist, yet continued to be offered only the same COTA while PT assessments proceeded. The Rehab Director acknowledged the refusals were due to dislike of the assigned COTA and indicated no alternative therapist was arranged, despite a facility policy requiring reasonable accommodation of individual needs and preferences, including adaptive devices and services.
A resident with quadriplegia and multiple comorbidities, using a specialized breath-activated call light, reported that staff were turning off the call light from the nursing station without entering the room or addressing their needs. A prior concern form documented the same allegation, and a nurse had admitted to deactivating the call light from the desk without checking on the resident. During the survey, the resident stated this practice was ongoing and described knowing the call light was turned off when the hallway bell stopped and no staff arrived, indicating a failure to respond appropriately to the resident’s requests for assistance.
The facility failed to accurately and completely report multiple abuse and neglect incidents to the State Agency. In one case, two residents with significant cognitive and physical impairments were involved in a dining room altercation where one resident allegedly grabbed another by the shirt, pulled her from a wheelchair to the floor, and continued swinging, causing reported pain to the victim’s arm and hip; however, the Facility Reported Incident minimized the event as unspecified "physical contact" and omitted these details. In another case, a quadriplegic resident using a breath‑activated call light alleged that staff were turning off the call light from the nurses’ station without responding, and a nurse admitted doing so, but this allegation of neglect was not reported to the State Agency as required by the facility’s abuse policy.
A resident with intact cognition and multiple behavioral and medical diagnoses reported being frightened when another resident entered her room wearing only a brief. In response, her care plan was updated to include a red Velcro stop sign on her door as a visual cue to discourage uninvited entry and to reinforce her rights to privacy and safety. During the survey, no stop sign was observed on her doorway on multiple occasions, despite the intervention remaining active in the care plan and the other resident’s room being directly across the hall. A CNA assigned to the resident reported never having seen such a sign for her, and the DON confirmed that the intervention should have been in place and that the facility had Velcro stop signs available, in contrast to facility policy requiring residents to receive the services and items in their care plans.
Surveyors found that one CNA did not receive the required 12 hours of annual in‑service education, with records showing only 7.75 hours completed. When surveyors requested training documentation for several CNAs, the staff development nurse, who also served as the IP, could only provide incomplete records for this CNA and could not explain why the deficiency had not been identified earlier. No additional documentation was produced, despite a facility policy assigning responsibility to staff development or HR to track in‑service education and to department managers to ensure timely completion.
Surveyors found that two CNAs did not receive the required annual 12 hours of in‑service education, specifically lacking mandated abuse prevention and dementia care training. Documentation showed one CNA had not had abuse and dementia education for an extended period, and another had no documented dementia care education. The Infection Preventionist/Staff Development nurse, responsible for tracking in‑service hours, could not account for these omissions and reported uncertainty about possible electronic record issues. Despite corporate oversight and a facility policy assigning responsibility for tracking and ensuring timely completion of in‑services, no additional documentation was produced to demonstrate that the required training had been completed.
Two residents were observed to have non-functioning call light systems, as repeated attempts to activate the call bell did not result in the indicator light outside their doors turning on. An LPN confirmed the malfunction, and interviews with the nurse unit manager, DON, and administrator revealed they were either unaware of ongoing issues or believed previous problems had been resolved. No additional documentation or explanation was provided during the survey.
A resident with a history of stroke and limited mobility, identified as requiring two-person assistance for bed mobility, was turned in bed by a single aide despite warnings from the resident. This resulted in a fall, head injury, increased pain, and trauma. The aide, who was newly hired, did not follow proper positioning techniques, and the care plan was not clearly specified in the Kardex, leading to the deficiency.
A resident with quadriplegia who required a 20 French suprapubic catheter did not receive the correct catheter size because the facility ran out of supplies and failed to track inventory effectively. An 18 French catheter was used temporarily, but the correct size was not available for two days, leading to leakage, discomfort, and ultimately a UTI that required hospitalization. The care plan and physician orders lacked clear documentation of catheter size, and there were communication gaps between nursing, supply staff, and leadership, resulting in delayed intervention and inadequate care.
Multiple residents with high acuity needs experienced significant delays in care, such as waiting up to an hour for assistance with transfers, toileting, and water, due to insufficient CNA staffing. Staff and residents reported that care was frequently delayed, showers were missed, and basic needs were unmet, especially when units were staffed below the expected levels. Documentation confirmed that the facility was routinely understaffed for its census and acuity, and issues with linen availability further impacted timely care.
The facility failed to provide sufficient nursing staff, resulting in delayed care and services for residents. Observations and interviews revealed inadequate staffing, particularly during evening and night shifts, with residents reporting unanswered call bells and delays in receiving medication. Staffing data indicated low weekend staffing, and assignment sheets showed multiple shifts with insufficient staff. Residents expressed concerns about long waits for assistance, and the facility's reliance on census rather than acuity for scheduling contributed to the issue.
The facility's kitchen was found to be unsanitary, with improperly labeled and stored food items. Unsealed and undated packages of sausage patties, chicken breasts, and hot dogs with ice crystals were observed in the freezer. Additionally, pans were improperly stored with water inside them. The Dietary Manager acknowledged these issues, which contradict the facility's sanitation policy.
The facility failed to properly implement transmission-based precautions for several residents, leading to potential infection spread. Observations showed discrepancies in Enhanced Barrier Precautions (EBP) signage and orders, with some residents' rooms displaying EBP signs without corresponding clinical orders. A nurse was seen providing care without required PPE, and a resident was placed on contact precautions without documented orders. The facility's protocol for reviewing referrals and discharge records was not consistently followed, resulting in improper infection control measures.
A facility failed to update a resident's care plan to include non-pharmacological interventions for managing depression and insomnia. Despite a psychiatric evaluation recommending techniques like increased sunlight exposure and regular human contact, the care plan lacked these individualized interventions. The social worker acknowledged the omission and the need to revise the care plan.
The facility failed to meet professional standards in medication administration for two residents. One resident refused Miralax, but the nurse incorrectly documented it as given. Another resident reported late insulin administration, with records showing it was given much later than scheduled. Facility policy requires accurate documentation and timely administration, which were not followed.
A resident with diabetes experienced multiple instances of elevated blood glucose levels exceeding 400, yet the facility failed to consistently notify the physician or document additional insulin orders as required. Interviews with nursing staff revealed a lack of documentation and communication regarding these elevated levels, despite the facility's policy on change in condition notification.
A facility failed to ensure accurate physician documentation for a resident, leading to discrepancies in progress notes and an incorrect discharge summary. The resident, who expired in the facility, had missing documentation regarding a fall and an erroneous discharge note. The physician attributed the error to the electronic medical record system and their workload across multiple facilities.
A facility failed to implement individualized non-pharmacological interventions for a resident prescribed psychotropic medications for depression and insomnia. The resident's care plans and records lacked targeted behaviors and non-pharmacological strategies, and no gradual dose reductions were attempted. The social worker confirmed the absence of a care plan addressing these issues, leading to a deficiency finding.
The facility exceeded the acceptable medication error rate with two errors observed during medication administration. A nurse incorrectly measured Miralax using a liquid medication cup, leading to an inaccurate dose. Another nurse administered a lower dose of Vitamin D than prescribed, giving 400 IU instead of the required 1000 IU. These errors resulted in a 7.69% medication error rate.
A facility failed to properly store and manage medications, as a resident had a tube of hemorrhoid cream on their nightstand without a self-administration assessment. Additionally, a medication cart inspection revealed a loose pill, expired medications, and insulin pens not managed according to policy and manufacturer guidelines.
A resident in an LTC facility was involved in an altercation where they hit another resident. Despite the incident being reported to staff, the facility failed to notify the abuse coordinator and the State Agency as required. The aggressor had a history of severe cognitive impairment, and the victim required assistance with daily activities. The facility's policy mandates immediate reporting of such incidents, which was not adhered to in this case.
A facility failed to provide adequate supervision and implement elopement policies, resulting in a severely cognitively impaired resident being unsupervised and found miles away. The resident exited through an unlocked gate used as a main entrance due to repairs, with staff untrained in monitoring responsibilities. Another resident with wandering behaviors accessed a construction zone multiple times, with ineffective interventions and insufficient staff awareness.
Failure to Complete Required Annual CNA Skills Competency Evaluations
Penalty
Summary
The facility failed to ensure that nursing staff received required skills, competencies, and performance evaluations for five of five CNAs reviewed for education and training. Surveyors requested CNA skills competency documentation for five CNAs and found that the most recent evaluations were not consistently completed on an annual basis. Specifically, CNA Y’s most recent skills competency evaluation was dated 7/18/24, CNA Z’s was dated 8/8/24, CNA AA’s was dated 1/23/24, CNA BB’s was dated 11/2/22, and CNA CC’s was dated 6/27/24. These dates showed that at least one CNA had not had a skills competency evaluation for more than a year. During an interview, the Infection Preventionist/Staff Development nurse stated they had been in the staff development role since mid-October 2025 and described the process as reconciling that skills competencies were done upon hire. When asked about annual skills competency evaluations to determine areas needing improvement, the nurse reported they were not aware that annual evaluations were required. When asked about corporate oversight or support, the nurse stated that such oversight existed but could not provide further explanation. The facility’s own policy titled “Skills Evaluations,” dated 2/9/2024, states that skills evaluation checklists are to be completed during job-specific orientation, re-validated annually, and completed as needed, which was not followed for the CNAs reviewed.
Widespread Environmental and Housekeeping Failures Affecting Resident Living Areas and Shower Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, safe, comfortable, and homelike environment throughout multiple resident care areas, including shower rooms and resident rooms on several units. During a building tour, surveyors observed shower rooms with vinyl fabric liners under shower beds filled with cloudy liquid that smelled of urine; when tipped, the liquid drained through a liner drain hole with attached tubing. These liners were visibly soiled and stained brown, and the Director of Housekeeping & Laundry stated they were not laundered and that CNAs were responsible for cleaning them. In multiple shower rooms, floors were visibly soiled with buildup under and around therapy tubs, caulk at the floor/wall juncture was torn or missing and soiled with a black substance, and a lower plastic shelf under a shower bed was visibly soiled. The Director of Housekeeping acknowledged the need for re‑caulking and cleaning and reported that shower rooms were supposed to be cleaned daily with monthly deep cleaning, but the observed conditions did not reflect that schedule. Additional observations in resident rooms showed widespread uncleanliness and lack of routine housekeeping. One resident’s room had a floor littered with debris and numerous stains near the head of the bed and around the nightstand. Another resident’s room had dried purple streaks on the closet door and adjacent walls. A different room was cluttered, with a sticky floor scattered with debris that appeared not to have been mopped. A shared room had dirty floors with food crumbs, including scrambled eggs, and trash around both beds, and these conditions persisted on re‑observation the following day, when the bathroom was also found with two wheelchairs stored inside, a pink stain on the toilet seat, discolored toilet water with a film, and black stains in the bowl. In another room, the bed linens had been stripped and thrown on the floor under the window, and the floor at the foot of the bed had copious skin flakes and light brown sticky stains near the nightstand. One resident reported that housekeeping used to sweep and mop daily but recently only came about once a week, described the environment as not sanitary, and stated that unpleasant odors were frequent and sometimes prompted them to go to dialysis just to get away from the smell. Common areas and hallways also showed environmental deficiencies. Surveyors noted very strong urine and bowel movement odors throughout hallways on two units, including near a central shower room where no specific source was identified. Flooring outside and inside one resident’s room was covered with a clear, sticky substance that remained in place on subsequent observation, with a mechanical lift stored directly over it. The same room had a strong urine odor, heavily damaged walls with deep grooves, peeling floor molding with exposed debris, and scattered food debris and trash. Wallpaper throughout the hallways was heavily soiled with purple and brown splatters and peeling away from the walls. Handrails across from a housekeeping closet and near a main lounge had separated sections and missing end caps, exposing sharp metal and plastic edges; a resident was observed propelling their wheelchair by pulling along the exposed area. A housekeeping closet containing several cleaning chemicals was found open and unsecured with no housekeeping staff nearby, and a housekeeper acknowledged it should have been locked. The Maintenance Director confirmed the presence of sharp handrails, missing end caps, peeling wallpaper, and peeled floor molding, and identified a broken pin under a shower bed that should have secured a bed rail, stating it should have been reported and the bed should not have been available for use. The Director of Housekeeping, in place for about a month, reported staffing vacancies, stated that rooms were supposed to be cleaned daily using a checklist, acknowledged housekeeping concerns and the stained hallways, and confirmed that the housekeeping closet should remain locked. Review of the facility’s electronic reporting system from late September through early February showed no entries for the observed environmental issues, despite facility policies requiring a clean, sanitary, orderly environment, pleasant neutral scents, and safe chemical storage. The facility’s own policies on a homelike environment and chemical storage state that staff are to provide a clean, sanitary, and orderly environment with pleasant, neutral scents, and that housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. Staff are directed to report lingering odors, bathrooms needing cleaning, and unresolved environmental concerns to administration, and chemicals are to be stored safely. Despite these policies, surveyors documented persistent odors of urine and bowel movements, visible dirt and debris in resident rooms and hallways, stained and soiled surfaces, improperly maintained shower equipment, unsecured chemicals, and unreported maintenance issues such as damaged handrails, peeling wallpaper, and broken shower bed components. Residents interviewed reported decreased frequency of housekeeping services and dissatisfaction with cleanliness and odors in the facility, aligning with the environmental conditions observed during the survey.
Failure to Provide and Document Adequate ADL Hygiene and Bathing Care
Penalty
Summary
The deficiency involves the facility’s failure to provide and document adequate ADL care, including personal hygiene, bathing, and nail care, for multiple dependent residents. One resident reported that there were sometimes not enough aides on the unit and stated it took a long time to get assistance, resulting in missed scheduled bed baths and going about a week without a bed bath. Review of this resident’s CNA task documentation over a 30‑day period showed a bed bath on 1/21/26, with the next not until 1/28/26, and the last documented bed bath on 2/3/26. Another resident with severely impaired cognition, dependent on staff for all ADLs, was repeatedly observed in the same hospital gown with a persistent foul, sour body odor in the room. This resident’s fingernails were long, with debris under the nails, and the fingers were contracted into the palms. When the unit manager partially opened the contracted hand, a very strong foul, bitter, sour odor emanated from the palm, which the manager confirmed. The unit manager stated the resident was scheduled for a shower later that day and reported that about a month earlier the therapy department had worked with the resident to clean the palm of the hand. Review of this resident’s CNA bathing task documentation for the prior 30 days showed the last scheduled shower documented on 2/3/26. A third resident, with vascular dementia, hemiparesis, ROM impairment, and dependent for showers/baths and personal hygiene, had family concern forms documenting delays in personal care, including being left in bed undressed and in the same facility gown with a strong urine smell from the bed, suggesting unchanged linens. The ADL care plan called for assistance with scheduled and as‑needed bathing/showering via gurney with two‑person assist, but shower/bath documentation for the past 30 days showed only one shower, with no refusals documented. A fourth resident, cognitively intact and dependent on staff for toileting hygiene and bathing, reported preferring showers but stated that when there was not enough nursing staff they received a bed bath or no shower. Review of this resident’s record showed only three showers documented in the past 30 days, with no refusals, despite a care plan specifying assistance with ADLs and a preference for a specific shower chair. The DON stated that CNAs were instructed to document all showers/baths in the electronic medical record and that no additional shower forms were used. The facility’s ADL policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain grooming and personal hygiene.
Insufficient Nursing Staff Leading to Missed and Delayed ADL Care
Penalty
Summary
Surveyors identified a failure to provide sufficient nursing staff to meet residents' needs, particularly on the second floor, resulting in delayed or missed ADL care such as incontinence care, dressing, showers, and getting residents out of bed. The facility’s own facility assessment, last updated 1/15/26, outlined expected daily staffing levels for licensed nurses and CNAs on each unit, but review of assignment sheets, census, and time punch reports for specific dates showed multiple call‑offs and staffing that did not meet those levels. The DON acknowledged that Unit 1 should have three CNAs on day shift and that the staffing documentation confirmed this was not consistently achieved. The facility’s staffing policy stated that licensed nurses and nursing assistants would be available 24/7 and that staffing numbers would be based on resident needs and the facility assessment, but the actual staffing patterns did not align with these standards. Multiple residents reported that inadequate staffing led to missed or delayed care. One resident stated they had been left an entire shift without incontinence care, especially on night shift, and that they did not receive their scheduled bed baths. Another resident reported missing therapy sessions because there were not enough staff to get them ready, and therapy documentation showed at least one missed session due to the resident having a bowel movement and later dinner, and another session where the resident remained supine in bed in a gown, requesting in‑room therapy because they were not yet dressed. A resident reported that their roommate’s family repeatedly requested that the roommate be gotten out of bed, but staff left her in bed every day; the same resident described frequent situations with only one nurse and two aides for the hallway, long waits for assistance over 30 minutes, missed showers, and a recent weekend when residents were not gotten out of bed and meals were served in rooms. Additional interviews corroborated ongoing staffing shortages and their impact on care. On a morning when three CNAs were scheduled for Unit 1, one CNA was not present, and the nurse could not explain who was covering that CNA’s assignments; residents listed as “early get up” were still in bed, undressed, and in hospital gowns. Another resident reported that sometimes there was only one CNA for all of Unit 1 and part of Unit 2, resulting in long waits and a missed scheduled shower or bed bath the prior week. During a resident council meeting, several residents reported untimely call light response, being forced to accept showers at times chosen by CNAs rather than their preferred times, being left in bed until early afternoon or for entire weekends, and a night shift that “disappears” with call lights going unanswered for hours. A CNA reported multiple call‑offs on a recent Sunday, no management assistance that day, and an inability to complete all assigned tasks when working short. The DON and Administrator both acknowledged challenges with staffing and excessive call‑offs, and HR reported ongoing hiring efforts and instability in the scheduler position.
Medication Pass Errors Resulting in 19% Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 25 opportunities (19%) during a medication pass involving three residents. For one resident (R57), a nurse prepared and administered a set of morning medications, including magnesium oxide 400 mg, folic acid 400 mcg, and gabapentin 100 mg. The nurse crushed all medications, including the gabapentin capsule, and mixed them with applesauce before administration, then confirmed all medications due had been given. Subsequent reconciliation with the physician’s orders showed that the ordered dose of magnesium oxide was 440 mg, and the ordered dose of folic acid was 1 mg, not 400 mcg as administered. It was also discovered that an ordered dose of famotidine 20 mg for this resident was not prepared or administered at that time. For another resident (R92), a nurse prepared and administered medications that included a sennosides 8.6 mg tablet. When the administered medications were reconciled with the physician’s orders, it was found that the resident did not have an order for sennosides alone, but instead had an order for Senna-S, a combination product containing sennosides 8.6 mg and docusate sodium 50 mg. During an interview, the DON stated that gabapentin capsules should not be crushed but opened and the contents emptied, and that nurses are expected to follow the rights of medication administration (right resident, medication, dose, route, time). The facility’s medication administration policy, reviewed in 2/2026, requires safe and accurate preparation and administration of medications according to physician orders and professional standards, adherence to the rights of medication administration, and not crushing medications when contraindicated or without a physician’s order.
Failure to Honor Resident Choice for Wheelchair Seatbelt and OT Provider
Penalty
Summary
The deficiency involves the facility’s failure to honor resident self-determination and support resident choice for two residents regarding adaptive equipment and therapy provider preferences. One resident reported that they previously used a wheelchair seatbelt at an outpatient day program, which provided a sense of security and safety. After discontinuing the day program and receiving a different wheelchair in the facility, the resident repeatedly requested a seatbelt but stated the facility refused to equip the new wheelchair with one. The resident reported being physically able to unbuckle the seatbelt independently and said staff told them they could not have a seatbelt because “the State doesn’t allow it,” which the resident believed was untrue. Surveyors interviewed the Rehab Director, who initially denied knowledge of the resident’s request for a seatbelt and indicated they would look into the request and perform an assessment. The Administrator was later informed that the resident had been told the State did not allow a seatbelt and acknowledged that this was an inappropriate response. The report notes that the facility’s own policy on Accommodation of Needs requires evaluation and reasonable accommodation of residents’ individual needs and preferences, including adaptive devices, upon admission and on an ongoing basis. The second resident expressed ongoing complaints about rehabilitation services, specifically regarding OT. This resident stated that after frequent hospital transfers, PT would assess them upon return, but they refused OT assessments because they did not want PT services and preferred OT services from someone other than the current COTA. The resident reported disliking the assigned COTA and refusing treatment from that individual, while being willing to work with another therapist. Documentation showed the resident had previously filed a concern form requesting a different OT, and progress notes recorded repeated refusals of OT evaluations, with the resident stating they would wait until a new therapist was hired. The Rehab Director confirmed the refusals were due to the resident’s dislike of the COTA and stated they did not think the contract company would send another COTA for one resident. The Administrator later stated they were not aware of the resident’s ongoing concerns but acknowledged they should have been informed and that something should have been done to accommodate the resident’s preferences.
Neglect Related to Call Light Response for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency related to neglect when a resident with quadriplegia reported that staff were turning off their call light from the nursing station without responding to their needs or requests. A facility Concern Form dated 8/4/25 documented that the resident alleged staff turned off the call light from the desk without completing the requested task. During the facility’s internal inquiry, a nurse admitted to turning off the resident’s call light from the nursing station without going to the room to determine why the call light had been activated. During the survey on 2/11/26, the resident was observed in bed using a specialized, breath-activated call light designed for individuals with limited or no motor skills. In an interview at that time, the resident stated that staff were still turning off the call light from the nursing station without coming to the room. The resident explained they could tell the call light was deactivated from the desk because the hallway bell would stop sounding and no one would enter the room. The resident also reported that, in the past, the Administrator had been present in the room, activated the call light, and witnessed staff deactivating it from the nursing station without checking on the resident. The resident’s clinical record showed diagnoses including quadriplegia, peripheral vascular disease, chronic pain, pressure ulcers, neuromuscular dysfunction of the bladder, presence of a suprapubic catheter, and urinary tract infections. The facility’s abuse policy defined neglect as the failure of the facility or its employees to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.
Failure to Accurately Report Resident Abuse and Alleged Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to accurately and completely report a resident‑to‑resident physical abuse incident to the Abuse Coordinator and State Agency. The Facility Reported Incident submitted on 11/3/25 described only that physical contact was made by one resident toward another, that one‑on‑one supervision was initiated, and that an investigation began, but it did not document the type of physical contact. In contrast, the nursing progress note for the involved resident documented that a CNA reported one resident rolled up to another in the dining area, grabbed the resident by the collar, pulled her to the floor, and that the resident had pain in her right arm and hip. The internal investigation file further documented that the incident occurred in the dining room, that the resident fell from the wheelchair related to the incident, and that the aggressor approached from behind and made physical contact resulting in the fall. During interview, the CNA witness stated that the aggressor grabbed the other resident out of the chair by her shirt, would not let go, the resident fell to the floor, and the aggressor continued swinging with one arm until separated by staff. The Administrator, who served as Abuse Coordinator, acknowledged that the report to the State Agency should have contained more detail to explain what actually happened. The deficiency also includes the facility’s failure to report an allegation of neglect involving staff response to a resident’s call light. A Concern Form dated 8/4/25 documented that a resident alleged when the call light was pressed, staff turned off the call light from the desk without completing the requested task. The form recorded a verbal statement from a nurse during the Administrator’s investigation in which the nurse admitted to turning off the call light without addressing the resident’s issues. In a subsequent interview, the Administrator confirmed recalling the incident, identified the nurse who admitted to turning off the call light from the nursing station without checking on the resident, and stated that this allegation of neglect was not reported to the State Agency. The residents involved had significant medical and functional impairments. One resident in the abuse incident had diagnoses including lupus, anxiety disorder, major depressive disorder, auditory hallucinations, cerebral palsy, and legal blindness, with an MDS showing moderately impaired cognition. The other resident in that incident had a history of brain injury and epilepsy with severely impaired cognition. The resident alleging neglect of call light response had quadriplegia and used a specialized breath‑activated call light, with additional diagnoses including peripheral vascular disease, chronic pain, pressure ulcers, neuromuscular bladder dysfunction, and a suprapubic catheter. This resident reported that staff were still turning off the call light from the nursing station, explaining that the hallway bell would stop sounding and no one would come to the room, indicating the light had been deactivated from the desk. The facility’s abuse policy required that all allegations of abuse and neglect be reported immediately to the Administrator and to the State Survey Agency within specified time frames, but the described events were not reported in accordance with that policy and regulatory expectations.
Failure to Implement Care-Planned Safety and Privacy Intervention After Resident-to-Resident Incident
Penalty
Summary
Surveyors found that the facility failed to implement a care-planned intervention for a resident who had requested enhanced safety and privacy measures after a resident-to-resident incident. A complaint reported to the State Agency documented that one resident entered another resident's room wearing only a brief and frightened the resident. The affected resident had diagnoses including generalized anxiety disorder, recurrent moderate major depressive disorder, adjustment disorder, osteochondrodysplasia with defects of growth of tubular bones and spine, short stature due to an unspecified endocrine disorder, and neuralgia and neuritis, and was assessed as having intact cognition. In response to the resident’s expressed desire for enhanced safety and privacy, the care plan initiated by a former MDS coordinator included placing a red stop sign on the resident’s door as a visual cue to discourage uninvited entry and reinforcing the resident’s rights to privacy and safety. During multiple observations on different days, surveyors noted that there was no Velcro stop sign placed within the resident’s doorway, despite the care plan intervention remaining active and not discontinued. Another resident involved in the prior incident was observed lying in bed in a room located directly across from the affected resident’s room. In an interview, the CNA assigned to the resident stated they had worked at the facility for a year and had never seen a Velcro stop sign for that resident. The DON, who began employment after the incident and after the care plan was initiated, confirmed that if the intervention was in the care plan it should have been in place, and acknowledged that Velcro stop signs were available in the facility. The facility’s policy on comprehensive care plans stated that each resident has the right to receive the services and items included in their plan of care.
Failure to Ensure Required Annual In‑Service Hours for a CNA
Penalty
Summary
The facility failed to ensure that one of five reviewed CNAs, identified as CNA AA, received the required 12 hours of annual in‑service training, as documentation showed only 7.75 hours of education completed for 2024. On the morning of 2/11/26, surveyors requested in‑service/education training hour records for five CNAs (Y, Z, AA, BB, and CC), and the records provided demonstrated the shortfall for CNA AA. During an interview later that day, the Infection Preventionist/Staff Development nurse (Nurse C), who had been in the staff development role since mid‑October 2025, stated they were responsible for reconciling education hours and suggested there might have been an electronic system issue, but confirmed that the documentation provided was all they could locate. Nurse C reported there was corporate oversight but could not explain why the facility had not identified CNA AA’s lack of required education/training, and no additional documentation was produced by survey exit. The facility’s own policy, “In‑Service Tracking” dated 2/4/2024, states that the Administrator will appoint a Staff Development Nurse or HR representative to track in‑service education and that department managers will assure timely completion of student in‑service education.
Failure to Provide Required Annual CNA In‑Service Training on Abuse and Dementia Care
Penalty
Summary
The facility failed to ensure that required annual in‑service education, including abuse prevention and dementia care, was completed for two of five reviewed CNAs. Surveyors requested documentation of in‑service/education training hours for five CNAs, and the records showed that one CNA (AA) last received abuse and dementia care education nearly two years prior, and another CNA (CC) had no documented dementia care education at all. These gaps meant the CNAs did not meet the requirement for 12 hours of in‑service training within the required time period, specifically lacking the mandated topics of abuse prevention and dementia care. During an interview, the Infection Preventionist/Staff Development nurse stated they had been in the staff development role since mid‑October and were responsible for reconciling in‑service hours. They indicated uncertainty about whether the electronic system was malfunctioning and confirmed that the documentation provided to surveyors was all they were able to locate. The nurse reported there was corporate oversight but could not explain why the facility had not identified CNA AA’s lack of required education/training. No additional documentation was produced by survey exit. The facility’s own policy on In‑Service Tracking assigns responsibility to the Administrator’s designee (Staff Development Nurse or HR) for tracking in‑service education and to department managers for assuring timely completion, but the documented lapses showed this process did not ensure compliance for the CNAs involved.
Non-Functioning Call Light System in Resident Rooms
Penalty
Summary
The facility failed to ensure that the resident call light system was fully operable and functioning for two of three residents observed during an onsite investigation. During the survey, a call bell function test was conducted in the presence of an LPN, where the call light indicator outside a resident's door did not activate despite multiple attempts. The LPN confirmed that the call bell/light was not working. A similar observation was made with another resident, who also pressed their call bell several times without the indicator light activating outside their door, even after repeated attempts. Interviews with facility staff revealed that the nurse unit manager stated staff are alerted to call lights by beeping at the nurse's station or by the lights outside residents' doors, but denied being informed of any issues with the system. The DON acknowledged awareness of a previous issue with the call light system in July, which was believed to have been resolved the same day, and denied knowledge of any ongoing problems. The administrator also stated they were previously unaware of concerns with the call light system. No further explanation or documentation regarding the call light system's operability was provided by the end of the survey.
Failure to Provide Required Two-Person Assist Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, limited range of motion, and classified as a two-person assist for bed mobility was not provided the required level of assistance during care. Despite the resident's explicit warning to the aide that they were a fall risk and required two staff for turning, only one aide proceeded to turn the resident in bed. This resulted in the resident falling from the bed, hitting their head, and experiencing significant pain and trauma. The resident was subsequently sent to the hospital for evaluation and treatment. The resident's care plan and Kardex indicated a need for two-person assistance for bed mobility, but this was not followed at the time of the incident. The aide involved was newly hired and, according to facility records, had received bed mobility training during orientation. However, the aide did not use proper positioning techniques and rolled the resident away from themselves, leading to the fall. The incident report and facility investigation confirmed that improper positioning and failure to follow the two-person assist requirement directly contributed to the resident's fall and injury. Following the fall, the resident experienced increased pain, anxiety, and a decline in participation in daily activities. The resident reported ongoing pain, fear of being moved, and a reluctance to engage with staff. Medical records documented increased requests for pain medication and new orders for scheduled pain management. The facility's review of the incident identified that the Kardex allowed aides to choose the level of assistance, which should have been specified by therapy, contributing to the confusion and subsequent failure to provide adequate supervision and assistance.
Failure to Provide Proper Catheter Care Due to Supply and Communication Issues
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, who required a 20 French suprapubic catheter per physician order, was not provided with the correct catheter size due to the facility running out of supplies. Instead, an 18 French catheter was used as a temporary measure following a physician's order, with instructions to replace it with the correct size the next day. However, the 20 French catheter was not available for two days, and the resident continued with the smaller catheter, which led to leakage and discomfort. The facility's supply management process was found to be inadequate, as the staff responsible for ordering supplies did not track inventory systematically and relied on visual checks and staff notifications, resulting in the unavailability of the required catheter size. The resident's care plan and physician orders did not consistently specify the required catheter size, and there was a lack of clear documentation regarding the catheter size in use. Communication gaps were identified between nursing staff, central supply, and facility leadership, which contributed to the delay in obtaining the correct catheter. Additionally, there was confusion regarding the responsibility for ordering and tracking supplies, and the central supply clerk did not maintain a log or tracking system for inventory needs. The Director of Nursing (DON) and Nurse Practitioner (NP) were not promptly notified or did not conduct timely in-person assessments, and there was no documentation of a physician or NP visit during the critical period when the catheter issue occurred. As a result of the delay in providing the correct catheter size and the lack of timely intervention, the resident developed a urinary tract infection (UTI) and required hospitalization. The hospital records indicated that the suprapubic catheter tract closed, necessitating the placement of a urethral catheter and antibiotic treatment. The resident expressed dissatisfaction with the care received, noting that they were not kept informed about the availability of the correct catheter and did not see a physician during the incident. The facility's policies and procedures did not adequately address catheter sizing or supply management, contributing to the deficiency.
Failure to Provide Adequate Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the care needs of residents, as evidenced by multiple observations, interviews, and record reviews. Staff and residents reported that there were often not enough CNAs on duty, particularly on units with higher acuity residents who required full care and mechanical lifts for transfers. Staff described being unable to meet residents' needs in a timely manner, with some residents waiting up to an hour for assistance with basic care such as being put to bed after dialysis, toileting, or receiving water. The issue was compounded by inconsistent staffing, frequent staff turnover, and management staff assuming additional duties due to vacancies. Residents directly affected by the staffing shortages included individuals with significant medical needs, such as heart failure, renal failure, stroke, and paralysis, who were dependent on staff for bed mobility, transfers, and toileting. These residents reported feeling neglected, frustrated, and angry due to long wait times for care, missed showers, and delays in receiving water. Some residents also noted that their personal belongings, such as clothing, were not attended to for several days, and that their families were unable to reach staff to address concerns. Staff confirmed that care was often delayed, especially when only two aides were present on units where three were needed to meet the acuity and volume of care required. Documentation and staff postings revealed that the facility was routinely staffed below the expected number of CNAs for the census and acuity of residents. On several reviewed dates, there were only six or seven CNAs present on the day shift, despite a census of over 85 residents and a facility assessment indicating a need for more staff. Additionally, issues with linen availability further delayed care, as aides sometimes hid linens in resident rooms or sent clean linens to laundry, making them less accessible. Management acknowledged the staffing concerns and the impact on resident care, but the deficiency persisted at the time of the survey.
Inadequate Staffing Leads to Delayed Care and Services
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in complaints of delayed care and services. Observations and interviews revealed that staffing levels were inadequate, particularly during evening and night shifts. A resident reported that one nurse was responsible for two units, leading to unanswered call bells and delays in receiving pain medication and care. Staff members also confirmed that the facility was short-staffed, especially on weekends, affecting the timeliness of care provided to residents. The facility's staffing data from the PBJ system indicated low weekend staffing for the second quarter of 2024. Review of assignment sheets and call-in records showed multiple shifts with low staffing, including instances where units were left without a nurse. The facility's census on a specific date documented 66 residents, with several requiring extensive assistance, yet staffing was insufficient to meet their needs. Interviews with staff highlighted the reliance on census rather than resident acuity for scheduling, which contributed to the staffing issues. During a group meeting, residents expressed concerns about staffing levels, reporting long waits for assistance and medication due to short staffing. The facility's Staffing Coordinator and DON acknowledged the issue, noting that staffing was based on census rather than acuity. They also provided a list of current open positions, indicating a significant number of vacancies for both nurses and CNAs, further exacerbating the staffing challenges.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner and ensure that potentially hazardous food items were properly labeled and stored. During a kitchen tour, surveyors observed unsealed and undated packages of sausage patties, chicken breasts, and hot dogs in the reach-in freezer, all with ice crystals accumulated on them. When questioned, the Dietary Manager acknowledged that these meats would need to be discarded. Additionally, pans were found stored on dry racks with water puddled inside them, and the Dietary Manager confirmed that pans should not be stacked until they are dry. A review of the facility's policy on kitchen sanitation, dated February 2023, indicated that food service employees are expected to practice good sanitation in accordance with state and US Food Codes to minimize the risk of cross-contamination and illness spread through food.
Inadequate Implementation of Transmission-Based Precautions
Penalty
Summary
The facility failed to ensure appropriate infection control practices related to transmission-based precautions (TBP) for five residents, resulting in the potential for the spread of infection. Observations revealed discrepancies in the implementation of Enhanced Barrier Precautions (EBP) for residents. For instance, a resident's room continued to display EBP signage despite the removal of an indwelling urinary catheter, which was the initial reason for the precautions. Another resident's room had EBP signage without any corresponding order in their clinical record. Additionally, a nurse was observed providing care to a resident on EBP without wearing the required isolation gown. Further issues were identified with a resident who was placed on contact precautions without any documented order or indication for such precautions. The resident's room lacked adequate personal protective equipment (PPE), and the assigned nurse was unable to find documentation supporting the need for contact precautions. The facility's Director of Nursing acknowledged these discrepancies and indicated that the facility's protocol for reviewing referrals and hospital discharge records was not consistently followed, leading to improper implementation of infection control measures.
Failure to Revise Care Plan for Non-Pharmacological Interventions
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident, identified as R42, to include non-pharmacological interventions for managing depression and insomnia. R42 was admitted with diagnoses including major depressive disorder and required assistance with most activities of daily living. A psychiatric evaluation noted the continuation of medications such as trazodone for sleep and Wellbutrin for depression, alongside recommendations for non-pharmaceutical techniques like increasing sunlight exposure and regular human contact. However, the care plan did not reflect these non-pharmacological interventions. Upon review, it was found that the care plans for R42 did not address the resident's depression or insomnia with individualized, person-centered non-pharmacological interventions. The social worker acknowledged the absence of a care plan for these conditions and indicated the need to add such interventions. This oversight highlights a deficiency in ensuring that the care plan was comprehensive and updated to reflect the resident's needs and the psychiatric provider's recommendations.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that medication administration met professional standards for two residents. For one resident, a nurse prepared multiple medications, including Miralax, but the resident refused the Miralax. Despite this, the nurse signed the medication administration record (MAR) as if the Miralax had been given. The facility's policy requires that any refusal of medication be documented as such on the MAR, which was not followed in this instance. For another resident, there was a concern about the late administration of insulin. The resident reported that a newer nurse administered their insulin late, causing anxiety about missing the dose. The medical record showed that the insulin was administered at 4:45 AM, which was significantly later than the resident's usual schedule. The nurse involved claimed they were busy with another resident and signed the MAR late, but maintained that the insulin was given on time. The facility's policy requires medications to be administered according to the physician's schedule, with a one-hour window before or after the scheduled time, which was not adhered to in this case.
Failure to Notify Physician of Abnormal Blood Glucose Levels
Penalty
Summary
The facility failed to consistently follow physician's orders for notifying abnormal blood glucose levels and obtaining additional treatment orders for a resident with diabetes. The resident reported that their blood glucose levels were as high as 400 and 500, which is significantly above the recommended levels. The physician's orders required the nurse to contact the physician if a blood glucose level over 400 was obtained. However, a review of the resident's blood glucose levels revealed multiple instances where levels exceeded 400, yet there was no documented evidence that the physician or nurse practitioner was notified, nor were there any additional insulin orders documented or administered. Interviews with nursing staff revealed inconsistencies in communication and documentation practices. Some nurses claimed to have notified the physician, but there was no documentation to support these claims. The Nurse Practitioner stated they were aware of the elevated blood sugars and had been changing insulin orders, but there was no record of additional insulin coverage being ordered or given. The Director of Nursing acknowledged that staff were likely notifying the physician but failing to document these interactions, which is contrary to the facility's policy on change in condition notification.
Deficiency in Physician Documentation for Resident Care
Penalty
Summary
The facility failed to ensure that the physician's notes were accurately entered into the resident's record at each visit, specifically for one resident. The resident, who was admitted to the facility and later expired there, had several progress notes entered by the facility physician, Dr. 'J', with discrepancies in the timing and content of the documentation. Notably, there was a lack of documentation regarding a fall that required the resident to be transferred to the emergency department, and a discharge summary was inaccurately completed more than 30 days after the resident's death, indicating a discharge home with home health care, which was incorrect. Interviews with Dr. 'J' revealed that they typically documented progress notes within 30 days of a visit but preferred to do so on the same day. Dr. 'J' acknowledged the mistake in the discharge summary, attributing it to the high volume of facilities they visit and an error in the electronic medical record system that allowed such documentation. The facility's administrator was aware of the issue and indicated they would investigate further. The facility's policy requires physicians to evaluate the resident's condition and document a progress note during required visits, which was not adhered to in this case.
Lack of Individualized Non-Pharmacological Interventions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure individualized and person-centered non-pharmacological interventions were in place for a resident who was prescribed psychotropic medications. The resident, who was admitted with a diagnosis of major depressive disorder-recurrent, was receiving Wellbutrin and Trazodone for depression and insomnia, respectively. However, the medical record review revealed that there were no targeted personalized behaviors identified for the resident's insomnia or depression. Additionally, the care plans, physician orders, and medication administration records did not include any individualized non-pharmacological interventions aimed at reducing the use of these psychotropic medications. Furthermore, the facility did not attempt any gradual dose reductions of the resident's Trazodone or bupropion since their admission. The social worker confirmed that there was no plan of care addressing the use of the medications, individualized non-pharmacological interventions, or reduction of the medications. This lack of action and planning led to the deficiency identified during the survey.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by two medication errors observed during a medication administration observation involving four residents. The first error involved a nurse incorrectly measuring a dose of Miralax for a resident by using a medication cup intended for liquids, rather than the bottle cap designed to measure the correct 17 grams of powder. This resulted in an inaccurate dosage being administered to the resident. The second error occurred when a registered nurse administered an incorrect dose of Vitamin D to another resident. The nurse dispensed a 10 mcg tablet, equivalent to 400 IU, instead of the prescribed 1000 IU as documented in the resident's Medication Administration Record. The discrepancy was acknowledged by the nurse, who indicated they would follow up according to the facility's protocol. Both errors contributed to a medication error rate of 7.69%, exceeding the acceptable threshold.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and management of medications, as evidenced by several observations and record reviews. A resident was found with a tube of hemorrhoid cream on their nightstand, which was not stored in a locked compartment as required by facility policy. The resident indicated that they were unable to apply the cream themselves, and there was no assessment in their medical record for self-administration of the medication. This indicates a lapse in adherence to the facility's policy on medication storage and administration. Additionally, during an inspection of a medication cart, a loose pill was found and disposed of without verification of its identity. The cart also contained expired medications, including a bottle of fish oil and loratadine, which were not disposed of according to the facility's policy. Furthermore, an insulin pen was found in use beyond the recommended 28-day period, and another insulin pen lacked an open date, contravening both the facility's policy and the manufacturer's guidelines. These findings highlight deficiencies in medication management and storage practices within the facility.
Failure to Report Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of abuse was immediately reported to the abuse coordinator and the State Agency for three residents involved in an incident. On July 1, 2024, a concern was submitted to the State Agency alleging that one resident, R902, hit another resident, R903. During an observation and conversation, R901, another resident, confirmed witnessing the incident and reported it to the facility staff. Despite this, the facility did not report the incident to the State Agency as required. R903, who was involved in the altercation, was observed in a wheelchair and confirmed being hit by R902 on the side of the face and arm. R903 reported the incident to their nurse, but the facility's records did not show that the abuse coordinator or the State Agency was notified. R903's medical records indicated a history of dementia and adjustment disorder with anxiety, and they required assistance with most activities of daily living. The progress notes documented the altercation, but there was no evidence of immediate reporting to the necessary authorities. R902, who was identified as the aggressor, had a history of Huntington's disease, dementia, and bipolar disorder, with severely impaired cognition. The progress notes for R902 detailed the incident and the subsequent actions taken by the staff, including administering medication and maintaining one-on-one supervision. However, the Incident and Accident report did not indicate that the abuse coordinator was notified, and a review of the State of Michigan Facility Reported Incidents system showed no report for the incident. The facility's policy required immediate reporting of such incidents, which was not followed in this case.
Inadequate Supervision and Elopement Policy Implementation
Penalty
Summary
The facility failed to provide adequate supervision and implement elopement policies for a severely cognitively impaired resident, resulting in the resident being let out of a secured door to the patio by an unknown staff member. The resident was unsupervised and found approximately 36 hours later, about five miles away from the facility. The incident began when the resident exited the facility through an unlocked gate on the patio, which was being used as the main entrance due to repairs. The staff responsible for monitoring the patio area, including a housekeeper temporarily covering for the receptionist, were not adequately trained or informed of their responsibilities, leading to a lack of supervision. The facility's failure to maintain a log of residents entering and exiting the patio area and the absence of a doorbell or buzzer contributed to the resident's unsupervised departure. Interviews with staff revealed that the resident was not accounted for during shift changes, and assumptions were made about the resident's whereabouts without verification. The facility's elopement policy was not effectively implemented, as staff did not report the resident's absence promptly, and there was a lack of communication and coordination among staff members regarding the resident's status. Additionally, the facility failed to adequately supervise and implement effective interventions for another resident with a history of wandering behaviors. This resident used the elevator multiple times to leave the unit and enter a construction zone on the first floor, which was off-limits to residents. Despite having a wander alert bracelet, the resident was able to access the first floor without triggering alarms, and staff were not consistently aware of the resident's movements. The care plan for this resident did not include updated interventions to address the wandering behavior, and staff reported challenges in providing constant supervision due to staffing limitations.
Removal Plan
- Resident was missing in the facility, and after initiating the procedure for a missing resident and searching the facility, the resident could not be located. The receptionist who was responsible for supervising the resident while on the patio alone was immediately suspended, pending investigation. The resident has been returned to the facility, evaluated, and deemed stable with no negative outcomes.
- Residents who reside in the facility who are at risk for elopement have the potential to be affected. A facility-wide audit was conducted and residents in the facility had an elopement assessment completed to establish elopement risk, and wander guards were applied to residents as appropriate, with physician orders and care plans updated.
- Facility doors were checked by the Maintenance Department.
- The facility process changed and residents must be attended to on the patio by staff or family.
- The facility gate has been locked and will be observed by 1:1 staff member until a door camera is installed. The gate will remain locked at all times.
- Education was initiated for the facility staff by the Director of Nursing, Assistant Director of Nursing, and designee. Staff are educated on elopement policy, procedures for a missing resident, that residents are not allowed on the patio without being attended by staff or family, and that nurses are to complete a head count of their assignment at the start of their shift. Additionally, Nurse Aides and Nurses received an in-service to visualize residents throughout the shift to ensure residents are safe and accounted for. In the event that a resident cannot be located, a staff member will notify the nurse supervisor, administrator, or director of nursing of the possibility that a resident is missing. The supervisor will coordinate and document the search efforts. Any staff member and/or contracted staff who has not been educated will be educated before working their next shift.
- Patio gate will remain locked and secured.
- Director of Nursing, or designee, will audit 5x weekly to ensure that residents are not on the patio without being attended by staff or family, and that nurses are completing a head count of their assignment at the start of their shift, to ensure that all residents are in the facility and accounted for.
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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