The Laurels Of Hudsonville
Inspection history, citations, penalties and survey trends for this long-term care facility in Hudsonville, Michigan.
- Location
- 3650 Van Buren, Hudsonville, Michigan 49426
- CMS Provider Number
- 235327
- Inspections on file
- 29
- Latest survey
- August 26, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at The Laurels Of Hudsonville during CMS and state inspections, most recent first.
A resident called 911 and reported being abused and held against her will by staff. Two CNAs became aware of the resident's allegations but did not notify the facility's Abuse Coordinator or Administrator, and the incident was not reported to the State Agency as required by facility policy.
Staff failed to maintain the required head-of-bed elevation during tube feeding and did not consistently label tube feeding solutions and hydration bags with the date and time of initiation, as required by facility policy. These deficiencies affected multiple residents with complex medical needs who were dependent on enteral nutrition.
A resident with a history of stroke and total dependence on staff was administered two muscle relaxants, Methocarbamol and Baclofen, at the same time due to a failure to discontinue one medication when the other was started. This medication error was not recognized by nursing staff, resulting in the resident becoming somnolent and unarousable and requiring hospital evaluation.
A resident at a facility developed multiple unstageable pressure wounds on their feet, which were not promptly or adequately addressed, leading to serious infection and delayed healing. Despite being at risk for pressure ulcers, the resident's feet were not properly elevated, and the facility's care plan interventions were insufficient. The wounds were not evaluated by a wound care consultant until three weeks after the consultation was requested, and there was a lack of appropriate treatment orders. Additionally, a wound culture was not ordered when the resident showed signs of sepsis, contributing to the worsening of the resident's condition.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with unstageable wounds, as required by their infection control policy. Observations revealed no signage or PPE available, and staff did not use the necessary PPE during high-contact care. The resident's care plan and order recap report did not reflect the need for EBP, and an RN was unaware of the requirement, indicating a gap in staff training and policy implementation.
A facility failed to administer daily medications to a resident on dialysis days, resulting in missed doses of critical medications. The resident, with conditions such as hemiplegia and end-stage renal disease, did not receive their morning medications on dialysis days, and the facility lacked orders for dialysis in the resident's records. Interviews revealed that the nursing leadership was unaware of the missed doses and did not notify a physician.
A resident with a PEG/J tube experienced repeated clogging incidents due to inadequate care and maintenance by the facility. Despite hospital instructions to flush the tube with warm water and use liquid medications, the facility failed to implement these measures, resulting in multiple emergency department visits. Interviews revealed a lack of staff training and communication regarding PEG/J tube care.
A resident with complex medical needs experienced repeated clogged PEG/PEGJ tubes due to inadequate nursing competency and training, resulting in multiple hospital visits. The facility failed to ensure nursing staff had current skills and assessments for PEG/PEGJ tube care, leading to improper management and tube damage.
The facility failed to maintain an effective infection prevention and control program, lacking a current infection tracking report and proper hand hygiene practices. The ADON struggled with the new infection control system, and there was no tracking of employee illnesses. An LPN was observed not changing gloves or performing hand hygiene during a resident's wound assessment, potentially leading to cross-contamination.
A facility failed to appoint a legal surrogate for a resident deemed incapable of making informed medical decisions. Despite the resident's daughter frequently visiting and being expected to provide legal guardian paperwork, it had not been submitted. The Director of Social Services expressed concern and noted the need for a court-appointed guardian if documentation is not provided.
A facility failed to ensure that the responsible party for a cognitively impaired resident was informed of the risks and benefits of an antipsychotic medication and had consented to its administration. Despite a doctor's order for Lurasidone, there was no documentation that the Power of Attorney (POA) had been informed or had consented. The Director of Nursing and Nursing Home Administrator were unable to provide the necessary documentation during the survey.
A resident with dementia and diabetes, who was cognitively intact, had an active leg infection that was not updated in their care plan, leading to potential inconsistent care. The unit manager responsible for updates had left, and the DON and MDS nurse were believed to be responsible. The infection was not discussed in clinical meetings, and the PA only informed a floor nurse about the antibiotics, failing to notify the interdisciplinary team.
A facility failed to assess and monitor a resident with chronic kidney disease, leading to hospitalization due to a suspected UTI. The resident's catheter was not changed as ordered, increasing infection risk. Additionally, another resident's skin conditions were not identified or treated, despite being cognitively intact and reporting issues. The facility's policies on skin management were not followed, resulting in potential deterioration of the resident's well-being.
A resident with dementia, morbid obesity, and dysphagia experienced significant weight loss, which was not adequately monitored or addressed by the facility. Despite the addition of a nutritional supplement, the care plan lacked specific interventions for weight loss, and there was no evidence of consistent monitoring or medical referrals. The DON and NHA considered the weight loss desirable but failed to provide supporting documentation.
A facility failed to verify feeding tube placement before administering medication to a resident with a PEG tube, contrary to its policy. The LPN did not aspirate stomach contents as required, relying instead on listening for air bubbles. Interviews revealed a lack of adherence to the policy and unclear procedures, risking complications like aspiration pneumonia.
A resident experienced significant weight loss after admission, but the facility failed to identify and report this to the Medical Provider. Despite the resident's weight history showing a substantial decrease, progress notes inaccurately stated no weight loss. The facility's documentation lacked evidence of timely evaluation or intervention by the Medical Provider, and there was no consistent monitoring or referral for the resident's weight loss.
The facility failed to address pharmacy recommendations for two residents, leading to deficiencies in medication management. One resident with dementia and bipolar disorder had unreviewed pharmacy recommendations for lab values and an AIMS assessment. Another resident with a history of stroke had unreviewed recommendations for anticoagulant dosage reduction and nutritional supplement evaluation. These recommendations were not reviewed by the physician until prompted by the surveyor.
A facility failed to maintain complete and accurate medical records for a resident, resulting in potential miscommunication about the resident's healthcare status. An antibiotic order was noted in the EHR for treating the resident's lower legs, but there was no further documentation from nursing staff or medical providers. The ADON and PA acknowledged the lack of documentation, with the PA stating she had not finished documenting the treatment for chronic lower leg venous stasis dermatitis.
Failure to Report Resident's Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency for one resident. The resident, a female recently admitted to the facility, used her phone to call 911 and reported to the dispatcher that she was being held against her will, had been assaulted by staff, was not allowed to make phone calls, and implied that she had been sexually assaulted by staff. A CNA discovered the resident on the phone with 911, spoke to the dispatcher, and explained that the resident was confused and the call was a mistake. Despite being aware of the resident's allegations, the CNA did not notify the facility's Abuse Coordinator. Further interviews revealed that another CNA was also aware of the 911 call and the resident's abuse allegations but did not report the incident to the Administrator/Abuse Coordinator, assuming that the nurse would handle it. The Administrator/Abuse Coordinator was not aware of the incident or the police visit until interviewed by surveyors. The facility's policy requires that all allegations of abuse be immediately reported to the Administrator and appropriate state agencies, but this protocol was not followed in this case.
Failure to Follow Tube Feeding Protocols and Documentation Requirements
Penalty
Summary
The facility failed to follow professional guidelines and its own policies regarding the care of residents receiving tube feedings. For three residents reviewed, staff did not maintain the required elevation of the head of the bed during tube feeding, as care plans and facility policy specified a semi-Fowler's position (30-45 degrees) during and after feeding to prevent aspiration. Observations showed that the head of the bed was consistently below the required elevation, with one resident's bed at 10-20 degrees and another at 12-22 degrees during active tube feeding. Additionally, a CNA interviewed was unaware of the correct bed elevation required for tube feeding care. Further deficiencies were noted in the labeling and documentation of tube feeding solutions and hydration bags. For two residents, the tube feeding solutions and kangaroo flush bags were not labeled with the date and time of initiation, contrary to facility policy and standard practice. The Director of Nursing confirmed that the facility's standard is to label all tube feeding solutions and hydration bags with the date and time they are started. The affected residents had significant medical conditions, including cerebral palsy, cognitive communication deficits, respiratory failure, Parkinson's disease, and cancer, and were dependent on staff for all care needs.
Failure to Administer Medications According to Professional Standards
Penalty
Summary
A female resident with a history of stroke resulting in right-sided paralysis, blindness in one eye, and total dependence on staff for daily care was admitted to the facility. The resident had active orders for two muscle relaxants: Methocarbamol 500 mg three times daily (later increased to 750 mg in the morning) and Baclofen 10 mg three times daily. Both medications were administered concurrently, as documented in the electronic medication administration record. Hospital records indicated that the resident became somnolent and unarousable after receiving both medications, and emergency department staff reported that the facility had been giving both muscle relaxants at the same time. The facility's Director of Nursing confirmed that the error was not recognized by nursing staff, and the prescriber had not discontinued Methocarbamol when Baclofen was started.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of pressure injuries for a resident, resulting in serious infection and delayed wound healing. The resident was admitted with multiple health conditions, including chronic kidney disease, congestive heart failure, and muscle weakness, and was identified as being at risk for pressure ulcers. Despite this, the initial assessments did not document any existing pressure ulcers or skin conditions. However, within a short period, the resident developed multiple unstageable pressure wounds on both feet, which were not promptly or adequately addressed. Observations and interviews revealed that the resident's feet were not properly elevated, and the standard pillow used for elevation was ineffective, leading to the resident's heels resting directly on the mattress. The facility's care plan included interventions such as cueing the resident to reposition, but these were insufficient to prevent the development of pressure injuries. The resident reported difficulty participating in physical therapy due to the wounds, which was a setback in their recovery process. The facility's documentation and treatment of the wounds were inconsistent and delayed. The resident's wounds were not evaluated by a wound care consultant until three weeks after the consultation was requested, and there was a lack of appropriate treatment orders for the open wounds. Additionally, when the resident showed signs of sepsis, a wound culture was not ordered, and the empiric antibiotic therapy may not have been appropriate. The facility's failure to implement effective pressure-reducing interventions and timely wound care contributed to the worsening of the resident's condition.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident reviewed for infection control. The policy effective from April 1, 2024, required the use of EBP in addition to Standard Precautions for residents with infections or colonization with CDC-targeted multidrug-resistant organisms (MDROs), or those with wounds or indwelling medical devices. The policy specified that signage should be placed on the resident's door and Personal Protective Equipment (PPE) should be readily available to staff. However, during observations, no signage or PPE were available for the resident, and staff did not don the required PPE during high-contact care activities. The resident had unstageable wounds on both feet, with dressings that were saturated with drainage. During a dressing change, the Registered Nurse (RN) did not wear a gown, which was required for residents needing EBP. The resident's care plan and order recap report did not reflect the need for EBP. An interview with the RN revealed a lack of awareness about the necessity of EBP for the resident's wound care, indicating a gap in staff training and implementation of the facility's infection control policy.
Failure to Administer Medications Post-Dialysis
Penalty
Summary
The facility failed to provide daily medications for a resident undergoing dialysis, resulting in the resident not receiving their prescribed medications three times a week. The resident, who has diagnoses including hemiplegia, hemiparesis, gastroparesis, and end-stage renal disease, was not administered their morning medications on days they attended dialysis sessions. These sessions occurred every Tuesday, Thursday, and Saturday, and the resident typically returned to the facility around noon. Despite this schedule, the facility did not have orders for dialysis in the resident's records, and the medications were not administered after the resident's return. The Medication Administration Records (MAR) for August, September, and October revealed that the resident missed multiple doses of various medications, including those for blood pressure, bipolar disorder, acid reflux, allergies, iron supplementation, constipation, anxiety, lactose intolerance, and antiemetic purposes. Interviews with the Director of Nursing and Assistant Director of Nursing indicated a lack of awareness regarding the missed doses and the absence of physician notification. The facility did not provide the resident's daily medications after dialysis, leading to the deficiency noted in the report.
Inadequate PEG/J Tube Care Leads to Repeated Clogging Incidents
Penalty
Summary
The facility failed to ensure proper care and maintenance of a Percutaneous Endoscopic Gastric/Jejunum (PEG/PEG/J) tube for a resident, resulting in multiple incidents of tube clogging and several emergency department visits. The resident, who had diagnoses including hemiplegia, gastroparesis, and end-stage renal disease, experienced significant issues with the PEG/J tube, including abdominal distention and bile leakage. Despite hospital discharge instructions to flush the tube with 50 mL of warm water after all tube feeds and medications, the facility did not implement these instructions in a timely manner, leading to repeated clogging incidents. The facility's records revealed a lack of documentation and education for nursing staff regarding the care of the resident's PEG tube. There were multiple instances where the tube became clogged, and the facility failed to follow hospital instructions to prevent clogging, such as using liquid medications and ensuring proper flushing techniques. The resident's family and hospital staff repeatedly provided instructions to the facility, but these were not effectively communicated or implemented by the nursing staff. Interviews with facility staff, including a registered nurse and the Assistant Director of Nursing, highlighted a lack of knowledge and training regarding PEG/J tube care. The registered nurse admitted to not knowing about the availability of a clot buster medication and not having received a skills competency evaluation. The Assistant Director of Nursing acknowledged that the facility did not have complete hospital records and that the nursing staff was not informed of hospital instructions. This lack of communication and training contributed to the ongoing issues with the resident's PEG/J tube care.
Inadequate Nursing Competency in PEG/PEGJ Tube Care
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skills to care for residents with Percutaneous Endoscopic Gastric/Jejunum (PEG/PEGJ) tubes, leading to repeated incidents of clogged tubes and multiple hospital visits for one resident. The review of nursing staff files revealed that none of the five nursing staff members had current competency skills and assessments related to PEG/PEGJ tube care. This lack of training and competency resulted in the resident experiencing several instances of clogged tubes, requiring emergency department visits for replacement or unclogging. The resident in question had significant medical conditions, including hemiplegia, gastroparesis, and end-stage renal disease, and relied on a PEG/PEGJ tube for nutrition. Despite the resident's complex needs, the nursing staff, including RN I, lacked the necessary training to manage the PEG/PEGJ tube effectively. RN I admitted to not knowing how to properly manage the tube, which led to a split tube due to excessive pressure and ineffective use of medication to unclog the tube. The Assistant Director of Nursing confirmed that RN I was re-educated on PEG/PEGJ tube care after these incidents, but no other nurses received similar education.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of an appropriate infection surveillance system for tracking and trending infections. During an interview and record review, it was revealed that the Director of Nursing (DON) and the Infection Preventionist/Assistant Director of Nursing (ADON) did not have a current infection control tracking report for July and August 2024. The ADON was unable to provide a current list of residents on antibiotics and admitted to difficulties in using the new infection control system. Additionally, the facility's mapping of infections did not correlate with the resident infection line listing, and there was no tracking of employee illnesses despite a high number of staff call-offs due to sickness. The facility's infection prevention program was further compromised by inadequate hand hygiene practices during a wound assessment. An LPN was observed assessing a resident's skin condition without changing gloves or performing hand hygiene after touching contaminated areas. The LPN acknowledged the failure to remove gloves and perform hand hygiene after assessing the resident's anal area, which could potentially lead to cross-contamination and infection spread. The facility's infection prevention policy, last revised in October 2023, outlines the need for surveillance of infections, implementation of control measures, and prevention of infections. However, the facility did not adhere to these guidelines, as evidenced by incomplete data collection, lack of infection tracking, and inadequate hand hygiene practices. The failure to maintain a comprehensive infection control program and ensure proper hand hygiene during resident care poses a risk to the health and safety of all residents and staff.
Failure to Designate Legal Surrogate for Resident
Penalty
Summary
The facility failed to designate a legal surrogate for healthcare decision-making for a resident who was reviewed for advance directives. The resident was admitted to the facility and was determined by two physicians to be incapable of making her own informed medical decisions. Despite this, the facility's electronic medical records did not show any legal surrogate appointed to represent the resident. During an interview, the Director of Social Services reported that the resident's daughter, who frequently visits, was supposed to provide paperwork proving her status as the legal guardian but had not yet done so. The Director expressed concern over the lack of appropriate documentation and indicated the need to pursue a court-appointed guardian if necessary.
Failure to Obtain Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that the responsible party for a cognitively impaired resident, who was receiving antipsychotic medication, was informed of the risks and benefits associated with the medication and had consented to its administration. The resident, who was admitted with diagnoses including bipolar disorder and dementia with psychotic disturbance, had a Power of Attorney (POA) in place for medical decisions. Despite the presence of a doctor's order for the antipsychotic medication Lurasidone, there was no documentation in the Electronic Medical Record (EMR) indicating that the POA had been informed or had consented to the medication's use. During the survey, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were unable to provide documentation that the POA had been informed of the risks and benefits or had consented to the medication at the time it was started. Although a physician's note dated several months after the medication's initiation mentioned a risk/benefit analysis, it did not confirm that the POA had been informed or had consented. As of the survey's conclusion, no further documentation was provided to address this deficiency.
Failure to Update Care Plan for Resident's Active Skin Condition
Penalty
Summary
The facility failed to update the care plan for a resident with an active skin condition, resulting in the potential for inconsistent care. The resident, who was admitted with diagnoses including dementia and diabetes, was cognitively intact as indicated by a BIMS score of 15. Despite being treated for a leg infection, the care plan only noted a potential for impaired skin integrity and did not reflect the active condition. This oversight was discovered during a review of the care plan, which had not been updated since June 2023. Interviews with facility staff revealed a breakdown in communication and responsibility for updating care plans. The unit manager, who typically handled updates, had recently left, and the responsibility was believed to have shifted to the DON and MDS nurse. However, the ADON confirmed that the infection had not been discussed in clinical meetings, and the PA had not communicated the treatment to the interdisciplinary team, only notifying a floor nurse about the initiation of antibiotics. The facility's policy required care plans to be updated with significant changes, which was not adhered to in this case.
Failure to Monitor Resident Conditions and Skin Care
Penalty
Summary
The facility failed to properly assess, monitor, document, and notify the physician of changes in condition for a resident with chronic kidney disease and an overactive bladder, leading to the resident's hospitalization. The resident's family observed signs of distress and requested a urinary tract infection (UTI) test, but the facility did not promptly obtain a physician's order or conduct the necessary assessments. The resident exhibited symptoms of anxiety, confusion, and incontinence, yet vital signs were not documented, and the physician was not notified. The facility's failure to change the resident's foley catheter as ordered further contributed to the risk of infection. Another deficiency involved the facility's failure to identify and treat skin conditions for a resident with dementia and diabetes. Despite a cognitive assessment indicating the resident was intact, the resident reported painful skin issues that had not been evaluated. Upon examination, the resident had reddened and raw areas on the inner thighs, abdominal folds, and near the anus, which had not been identified during weekly skin assessments or daily care. The Physician's Assistant was unaware of these conditions, indicating a lack of communication and documentation by the nursing staff. The facility's policies on skin management and wound care were not followed, as evidenced by the lack of documentation and failure to notify medical providers of new skin conditions. The Nursing Home Administrator confirmed the absence of records regarding the resident's skin concerns prior to the date of the survey. This oversight resulted in the potential for deterioration of the resident's skin conditions and compromised their physical, mental, and psychosocial well-being.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately assess and monitor the nutritional status of a resident who experienced significant weight loss. The resident, admitted with diagnoses including dementia, morbid obesity, vitamin deficiency, and dysphagia, lost 33 pounds (12.3%) within the first month of admission and a total of 62 pounds (22.69%) over several months. Despite the significant weight loss, the facility's electronic medical records (EMR) did not show consistent monitoring or timely interventions, such as referrals to a medical provider. The care plan did not specifically address the weight loss, and although a nutritional supplement was added, there was no evidence of ongoing evaluation or adjustment of the care plan. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that they considered the weight loss desirable, yet they failed to provide documentation supporting this claim. A Registered Dietician's progress note from July indicated significant weight loss triggers but did not include a referral to a medical provider. The EMR review from October to August showed a lack of ongoing nutritional monitoring or documentation of referrals for the resident's weight loss. As of the survey exit, no further documentation was provided by the facility to demonstrate that the weight loss was appropriately addressed.
Failure to Verify Feeding Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure proper verification of feeding tube placement before administering medication to a resident, as per professional standards and facility policy. The resident in question, identified as Resident #72, was admitted with diagnoses including dementia and dysphagia, necessitating the use of a percutaneous endoscopic gastrostomy (PEG) tube for nutrition. The facility's policy required verification of tube placement by aspirating stomach contents before medication administration, a step that was not followed during the observed incident. During an observation, a Licensed Practical Nurse (LPN) administered medication to Resident #72 via the PEG tube without verifying the tube's placement by aspirating stomach contents. The LPN admitted to checking the placement earlier in the day but did not do so before the medication administration observed. Instead, the LPN relied on listening for air bubbles while flushing the line, which is not in accordance with the facility's policy. Interviews with the LPN and the Assistant Director of Nursing revealed a lack of adherence to the facility's policy and a lack of clarity regarding the procedure for verifying PEG tube placement. The facility's policy, aligned with professional guidelines, emphasizes the importance of verifying tube placement to prevent complications such as aspiration pneumonia, which can occur if the tube is not correctly positioned in the stomach or small intestine.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to identify and address a significant weight loss in a resident, referred to as R38, who was admitted with diagnoses including dementia, morbid obesity, vitamin deficiency, and dysphagia. From the date of admission, R38 experienced a weight loss of 33 pounds, or 12.3%, within less than a month, and a total weight loss of 69.8 pounds, or 25.85%, by June of the following year. Despite this significant weight change, there was no documentation in the Electronic Medical Record (EMR) indicating that the weight loss was identified and reported to the Medical Provider. Progress notes from medical provider encounters inaccurately stated that there was no weight loss, which was inconsistent with the resident's weight history. The facility's documentation did not reflect any timely evaluation or intervention by the Medical Provider regarding the resident's weight loss. Although a nutritional supplement was added to the resident's diet in December, there was no evidence of consistent monitoring or referral to the Medical Provider. The Registered Dietician's progress note, dated eight months after the initial nutrition note, acknowledged significant weight loss triggers but also failed to indicate a referral to the Medical Provider. The facility did not provide additional documentation to show that the significant weight change had been adequately monitored or addressed by the Medical Provider by the time of the survey exit.
Failure to Address Pharmacy Recommendations for Residents
Penalty
Summary
The facility failed to address pharmacy recommendations for two residents, leading to deficiencies in medication management. Resident R38, who was admitted with diagnoses including dementia, dysphagia, and bipolar disorder, had pharmacy medication reviews conducted in January and July of 2024. However, these recommendations were not reviewed by the physician. Specifically, a recommendation from January 2024 for lab values to be obtained and a July 2024 recommendation for an updated Abnormal Involuntary Movement Scale (AIMS) assessment were not acted upon until requested by the surveyor. Similarly, for Resident R59, who was admitted with a history of stroke, pharmacy medication reviews in July and August of 2024 were not reviewed by the physician. Recommendations included reducing the dosage of an anticoagulant and questioning the need for a nutritional supplement based on lab values. These recommendations were not reviewed by the physician until prompted by the surveyor. The facility's policy requires that pharmacy recommendations be reviewed and acted upon by the attending physician, but this process was not followed, leading to the identified deficiencies.
Incomplete Medical Records for Resident's Treatment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, leading to potential miscommunication and an unclear picture of the resident's healthcare status. Specifically, the electronic health record (EHR) for a resident showed an antibiotic order to treat the resident's lower legs, but there was no further documentation from nursing staff or medical providers regarding the skin condition. This lack of documentation was identified during a review of the resident's EHR. Interviews conducted during the investigation revealed that the Assistant Director of Nursing (ADON) acknowledged the absence of documentation from the Physician's Assistant (PA) regarding the resident's lower leg infection and evaluation. The PA confirmed that she began treating the resident with antibiotics for chronic lower leg venous stasis dermatitis but had not yet completed the documentation in the EHR. The facility's policy on documentation expectations requires that all facts and pertinent information related to treatment and resident condition be documented in a timely and organized manner.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
