The Orchards At Harper Woods
Inspection history, citations, penalties and survey trends for this long-term care facility in Harper Woods, Michigan.
- Location
- 19840 Harper Avenue, Harper Woods, Michigan 48225
- CMS Provider Number
- 235480
- Inspections on file
- 30
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Orchards At Harper Woods during CMS and state inspections, most recent first.
A resident with intact cognition and COPD experienced a verbal altercation with a nurse after a delay in receiving pain medication, during which both parties exchanged derogatory language. In a separate incident, two residents with impaired cognition were involved in a physical altercation, resulting in one sustaining a bleeding lip and facial redness. Staff did not maintain professionalism or effectively deescalate these situations, leading to both verbal and physical abuse.
The facility did not maintain RN coverage for eight consecutive hours daily, affecting all 132 residents. Staffing data revealed low weekend staffing and multiple dates without RN coverage. The Staff Scheduler cited hiring and retention challenges, while the DON emphasized the expectation for adequate coverage. The facility's policy requires staffing based on resident acuity, which was not met.
The facility failed to ensure CNAs completed the required 12 hours of in-service education annually for three CNAs. CNA E, CNA F, and CNA G did not receive the mandated training. Staff Developer B, new to the position, acknowledged being trained differently on fulfilling the CNAs' training requirements. The DON expected CNAs to meet their required training hours, as indicated in the facility's assessment.
The facility failed to maintain sanitary conditions for residents receiving tube feeding, as observed in three residents. Tube feeding poles and floors were found with dried formula over several days, indicating a lack of proper cleaning. The residents had severe cognitive impairments and were dependent on staff for daily activities. The Director of Nursing stated that nurses and housekeeping were responsible for cleaning spills, but the facility's cleaning procedures were not followed.
A facility failed to update a resident's care plan after a fall, despite multiple observations of the resident in unsafe conditions. The resident, with a history of Acute Respiratory Failure, Dementia, Anxiety, and Macular Degeneration, was found in various states of neglect, such as being halfway off the bed and walking barefoot. The care plan had not been revised since the previous year, contrary to the facility's policy requiring timely updates after incidents.
A resident with epilepsy and dysphagia was not provided with necessary adaptive equipment, specifically a sippy cup, despite a physician's order and facility policy. The resident struggled to drink from a foam cup, and staff interviews revealed a lack of follow-through in reordering the required equipment.
A resident with Cellulitis and Peripheral Vascular Disease did not receive documented skin treatments as ordered, with multiple dates missing from the Treatment Administration Record. The resident's right leg was observed with an undated bandage, and the DON confirmed that treatments were expected to be completed as ordered.
A facility failed to provide adequate pressure ulcer care for a resident with severe cognitive impairment and total dependence on staff. The resident was observed lying on their backside without necessary offloading interventions, despite being at high risk for skin breakdown. The resident's pressure ulcer progressed to an unstageable stage, and prescribed treatments were not consistently documented as completed. The DON confirmed the need for repositioning every two hours, indicating a lapse in adherence to the care plan and facility policy.
A resident with limited mobility and medical diagnoses of dysphagia and cerebral infarction was observed without the prescribed bilateral elbow/hand splint on two occasions. The facility staff, including the DON and Restorative Nurse, showed a lack of clarity regarding the responsibility for applying the splint, and no application schedule was provided, despite requests.
The facility failed to serve meals at a palatable temperature for three residents, leading to dissatisfaction. One resident reported cold and hard vegetables, while another stated all meals were not good. A third resident mentioned insufficient portions when the food was good. The resident council noted complaints about cold food and prolonged food cart presence. The facility's policy acknowledged temperature drops but did not adequately address them.
The facility failed to obtain consent or declination for influenza and pneumococcal immunizations for two residents. One resident's responsible party refused vaccinations, but documentation was missing. Another resident's consent sheet lacked signatures, and a disconnected phone line hindered obtaining consent. Both residents had significant medical conditions and required staff assistance.
The facility failed to document COVID-19 vaccination consent or declination for two residents. One resident's refusal was known but not documented, while another's consent attempt was hindered by a disconnected phone line, with no follow-up. Both residents had significant medical conditions and required staff assistance, yet the facility did not maintain required documentation as per policy.
A resident faced financial management issues due to an expired driver's license, limiting their ability to access funds and pay bills. The facility failed to assist in renewing the license, leading to a deficiency in resident rights as the resident was pressured to fill out an ACH form under threat of discharge.
A resident was not readmitted to the facility after hospitalization despite being cleared for return, due to perceived aggressive behavior. The facility failed to provide proper notice for a facility-initiated discharge, and did not communicate adequately with the resident's guardian or the ombudsman. The necessary discharge notice was not completed, leading to a deficiency citation.
The facility failed to provide fresh water in a timely manner, as observed with several residents having warm, dated water cups from the previous night. Residents expressed dissatisfaction with the lack of fresh water, and the facility's hydration policy was not followed. Despite this, the DON was unaware of any issues, indicating a communication gap.
A resident reported verbal abuse by a CNA, who referred to their buttocks derogatorily and refused care. The resident, admitted with multiple pelvic fractures, had previously informed staff of the CNA's behavior. The DON and NHA were notified, leading to the CNA's suspension and termination.
The facility failed to ensure call lights were accessible and promptly answered for two residents. One resident was without a call light cord, making it impossible to call for assistance, while another resident's activated call light went unanswered for over 20 minutes. The DON was unsure if rounds were completed to ensure call light functionality and accessibility, contrary to the facility's policy of prompt response.
The facility failed to maintain a sanitary environment, affecting all residents. Observations showed dirty linen and trash left in rooms and common areas, causing foul odors. Staff interviews revealed inconsistencies in responsibilities for removing soiled materials, contrary to facility policy.
A resident with Juvenile Rheumatoid Polyarthritis, dependent on staff for ADLs, did not receive scheduled showers due to a misunderstanding of their shower schedule. Despite a sign indicating shower times, the resident reported not receiving showers, and documentation showed several instances marked as not applicable. The DON confirmed the resident's showers were missed due to a staff error in understanding the schedule change.
A resident with diabetes and neuropathy experienced pain due to long toenails, as the facility failed to provide timely podiatry care. Despite being admitted months earlier, the resident was not seen by podiatry until much later, with a missed visit in between. The facility lacked a written policy for podiatry care, and documentation was insufficient, leading to a delay in necessary foot care.
Failure to Prevent Verbal and Physical Abuse
Penalty
Summary
The facility failed to prevent verbal abuse involving a resident and a nurse. The resident, who had an intact cognition and a diagnosis of Chronic Obstructive Pulmonary Disorder, reported that after requesting pain medication and cough syrup, there was a significant delay in receiving the medication. When the nurse finally responded, an argument ensued during which both the resident and the nurse exchanged derogatory language. The nurse admitted to using curse words, stating that she felt threatened and was attempting to protect herself, rather than to escalate the situation. Additionally, the facility did not prevent resident-to-resident physical abuse between two residents with impaired cognition. One resident was found with a bleeding lip and redness under the eye, and staff determined that the injuries were likely caused by the roommate, who was observed attempting to pull the injured resident out of bed. Both residents required staff assistance with mobility and transfers, and neither could articulate what had happened due to their cognitive impairments. Staff responded by separating the residents after the incident. The facility's policies require that residents be protected from all forms of abuse, including verbal and physical abuse. However, in these instances, staff did not maintain professionalism or effectively deescalate the situation, resulting in both verbal and physical altercations involving residents and staff.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week, potentially affecting all 132 residents. A review of the CMS Payroll Based Journal Staffing Data Report for the 1st quarter of 2025 indicated excessively low weekend staffing. The Daily Staffing Sheets for the same period revealed multiple dates without RN coverage, specifically on 10/15/25, 10/16/25, 10/25/25, 11/6/24, 11/13/24, 11/14/24, 11/18/24, 11/19/24, 11/20/24, 12/7/24, and 12/24/24. During an interview, the Staff Scheduler explained the difficulty in hiring and retaining RNs and noted that call-ins occur frequently. The Director of Nursing stated that the expectation is to have adequate RN coverage. The facility's Staffing and Scheduling policy emphasizes staffing according to resident acuity and needs, which was not met as evidenced by the lack of RN coverage on the specified dates.
Failure to Provide Required CNA In-Service Training
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) completed the required 12 hours of in-service education annually for three CNAs. CNA E, hired on March 1, 2022, CNA F, hired on March 16, 2022, and CNA G, hired on March 14, 2017, did not receive the mandated training. During interviews, Staff Developer B, who is new to the position, acknowledged being trained differently regarding the timing and method of fulfilling the CNAs' annual training requirements. The Director of Nursing (DON) expressed the expectation that CNAs should meet their required training hours. The facility's assessment indicated that in-service training must be sufficient to ensure the continuing competence of nurse aides, with a minimum of 12 hours per year.
Failure to Maintain Sanitary Conditions for Tube Feeding Residents
Penalty
Summary
The facility failed to maintain a sanitary environment for residents receiving tube feeding, as observed in three residents. On multiple occasions, the tube feeding poles and floors next to the beds of these residents were found with large amounts of dried formula. This unsanitary condition persisted over several days, indicating a lack of proper cleaning and maintenance. The residents involved had severe cognitive impairments and were dependent on staff for activities of daily living, making them particularly vulnerable to the effects of such deficiencies. The Director of Nursing acknowledged that the expectation was for nurses to clean spills and for housekeeping to address the issue when necessary. However, the facility's policy on daily cleaning procedures, which includes disinfecting high-touch items and damp mopping floors, was not adhered to in these cases. The failure to follow these procedures resulted in the unsanitary conditions observed, as the tube feeding poles and surrounding areas were not properly cleaned, compromising the cleanliness and safety of the residents' environment.
Failure to Update Care Plans for Resident Safety
Penalty
Summary
The facility failed to timely revise care plans to accurately reflect identified problems and interventions for a resident. On multiple occasions, the resident was observed in situations that indicated a lack of appropriate care and supervision. The resident was found halfway off the bed and on the floor, wearing a wet brief that was hanging off. The resident appeared confused and unsure about what to do when asked about their care. On subsequent days, the resident was observed without a brief, non-slip socks, and walking barefoot, indicating a lack of attention to their personal care and safety needs. The resident's medical record revealed a history of multiple diagnoses, including Acute Respiratory Failure, Dementia, Anxiety, and Macular Degeneration. Despite a recent fall, the care plan for falls had not been updated since September of the previous year, lacking substantial recent interventions. The Director of Nursing confirmed that the expectation is for care plans to be updated after a team review of any falls. The facility's policy requires comprehensive care plans to be patient-centered and consistent with the resident's rights, reflecting current standards of practice, which was not adhered to in this case.
Failure to Provide Adaptive Equipment for Resident
Penalty
Summary
The facility failed to provide adaptive equipment for a resident, leading to a deficiency in maintaining the resident's ability to perform activities of daily living. The resident, who has medical diagnoses of epilepsy and dysphagia, was observed struggling to drink from a foam cup and reported that they usually use a smaller sippy cup, which had broken two months prior. Despite a physician's order for a modified lightweight water cup and a directive to ensure the resident had a smaller drinking cup at their bedside, the resident was observed without the necessary adaptive equipment. Interviews with facility staff revealed a lack of follow-through in providing the required adaptive equipment. The Registered Dietitian mentioned that the Occupational Therapist had suggested the resident could use a regular foam cup, and the Director of Nursing acknowledged the previous use of a sippy cup but indicated a need to reorder one. The facility's policy on adaptive eating equipment emphasizes the importance of providing such equipment based on comprehensive assessments to help residents achieve their highest functioning potential, which was not adhered to in this case.
Failure to Document and Complete Skin Treatments
Penalty
Summary
The facility failed to complete and document skin treatments for a resident, identified as R93, who was observed with an undated bandage on their right leg. The resident, who had been admitted with diagnoses including Cellulitis of the Right Lower Limb and Peripheral Vascular Disease, was cognitively intact and required limited assistance with daily activities. A physician's order dated January 8, 2025, specified daily wound care for the resident's right lower leg, including cleansing with wound cleaner, applying medihoney, and covering with abdominal pads and kerlex. A review of the Treatment Administration Record (TAR) for January, February, and March 2025 revealed multiple dates where the prescribed treatments were not documented as completed. The Director of Nursing confirmed that the expectation was for treatments to be completed as ordered. The facility's policy stated that residents admitted with skin impairments should have appropriate interventions implemented to promote healing, with a physician's order for treatment and a treatment record initiated.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident with a history of severe cognitive impairment and total dependence on staff for activities of daily living. The resident, who was admitted with encephalopathy, was observed multiple times lying on their backside without the necessary offloading interventions, such as pillows under their sides, despite being at high risk for skin breakdown. The resident's medical record indicated a recurrent open area on the sacrococcyx, which had progressed to an unstageable pressure ulcer with eschar and serous drainage. The care plan required repositioning every two hours with pillows, but observations showed this was not consistently implemented. Additionally, the Treatment Administration Record for March 2025 revealed that prescribed treatments for the resident's pressure ulcer were not documented as completed on several occasions. The Director of Nursing confirmed that the resident should have been repositioned every two hours, highlighting a failure to adhere to the care plan and facility policy aimed at preventing facility-acquired pressure ulcers. This deficiency in care was identified through observation, interview, and record review, indicating a lapse in the facility's pressure ulcer prevention and management protocols.
Failure to Apply Prescribed Splint for Resident with Limited Mobility
Penalty
Summary
The facility failed to apply a splint/brace for a resident with limited mobility, as observed during a survey. The resident, who was admitted with medical diagnoses of dysphagia and cerebral infarction, was seen on two separate occasions without the prescribed bilateral elbow/hand splint in place. Instead, a towel was rolled up in the resident's left hand. The resident's medical records indicated an active physician order for the splint, but it was not applied as required. Interviews with facility staff revealed a lack of clarity regarding the responsibility for applying the splint. The Director of Nursing was unable to provide information on the application schedule for the splint, and the Restorative Nurse stated that the nursing staff was responsible for applying the splints, although the facility policy indicated that either restorative staff or a licensed nurse should handle this task. Despite requests, no application schedule for the splint was provided by the end of the survey.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a preferred and palatable temperature for three residents. Resident 20 expressed dissatisfaction with the meals, stating that the vegetables served were cold and hard, leading their daughter to purchase food from outside. This resident was cognitively intact, as indicated by a BIMS score of 15, and had multiple diagnoses including Chronic Obstructive Pulmonary Disease and Major Depressive Disorder. Resident 31 reported that all meals at the facility were not good, while Resident 94 mentioned that the food did not look good and that they were not given enough food when it was good. The resident council meeting minutes from February 2025 revealed multiple complaints about the food, specifically noting that food was cold upon arrival and that food carts were left on the units for extended periods. The facility's policy on food palatability and hot food temperatures, dated 2018, stated that hot foods should be held at or above 135°F and acknowledged that food temperatures would drop by the time they reached the residents. However, the facility did not adequately address the variance in food temperatures, leading to dissatisfaction among residents.
Failure to Obtain Immunization Consents
Penalty
Summary
The facility failed to obtain consent and/or declination for influenza and pneumococcal immunizations for two residents, leading to a deficiency. For one resident, identified as R34, the Infection Control Preventionist (ICP) was aware that the responsible party had refused all vaccinations, but the documentation of these refusals could not be located. The resident had medical diagnoses of Dysphagia and Cerebral Infarction and required staff assistance with bed mobility and transfers. The resident's mental status assessment indicated they were unable to complete the assessment, further complicating the consent process. For another resident, identified as R92, the facility provided a consent sheet that lacked signatures and had a note indicating a disconnected phone line. The resident had medical diagnoses of Cerebral Infarction and Sepsis, with an impaired cognition score and required staff assistance with bed mobility and transfers. The ICP acknowledged that the phone line was disconnected when attempting to obtain consent from the responsible party, but there was no follow-up action documented. The facility's policy required offering pneumococcal and annual influenza vaccines, but the lack of proper documentation and follow-up led to the deficiency.
Failure to Document COVID-19 Vaccination Consent or Declination
Penalty
Summary
The facility failed to obtain consent or declination for the COVID-19 immunization for two residents, R34 and R92, as identified during a survey. For R34, the Infection Control Preventionist (ICP) was aware that the responsible party refused all vaccinations, but the documentation of this refusal was not found. R34 was admitted with medical diagnoses of Dysphagia and Cerebral Infarction and had a Brief Interview for Mental Status score indicating they were unable to complete the assessment. R34 required staff assistance with bed mobility and transfers, yet no consent or declination documentation was provided by the end of the survey. For R92, the documentation provided lacked signatures and included a note about a disconnected phone line. R92 was admitted with diagnoses of Cerebral Infarction and Sepsis and had an impaired cognition score. The ICP mentioned that the phone line was disconnected when attempting to obtain consent from the responsible party, but there was no follow-up on this issue. The facility's policy required maintaining documentation for all residents and staff on COVID-19 vaccination, which was not adhered to in these cases.
Failure to Assist Resident with Financial Management
Penalty
Summary
The facility failed to ensure a resident's right to manage their finances and assist with community banking services, leading to a deficiency in resident rights. A resident, who was cognitively intact, expressed concerns about being harassed by the facility regarding bill payments and receiving an involuntary discharge notice. The resident had difficulty accessing funds due to an expired driver's license, which limited their ability to withdraw sufficient cash from the bank. Despite having the funds, the resident was unable to pay the full amount due to these banking limitations. The Business Office Manager (BOM) acknowledged the resident's use of a credit card for bill payments and noted that the resident began not paying the bill in full. Although the BOM assisted the resident in visiting a local bank, the expired driver's license prevented further transactions. The facility did not assist the resident in renewing the driver's license, which contributed to the financial management issue. The facility's policy states that residents have the right to manage their financial affairs, but the resident was pressured to fill out an ACH form under the threat of involuntary discharge.
Failure to Permit Readmission and Provide Proper Discharge Notice
Penalty
Summary
The facility failed to permit the readmission of a resident following hospitalization, violating the requirement to provide proper notice of a facility-initiated discharge. The resident, who had been living at the facility since March 2024, was hospitalized after exhibiting aggressive behavior, including hitting doors and using vulgar language towards staff. Despite being medically and behaviorally cleared for return by the hospital, the facility refused readmission, citing an inability to accommodate the resident's needs due to their aggressive behavior. The facility did not complete the necessary involuntary discharge notice, nor did they communicate adequately with the resident's guardian or the ombudsman about the decision not to readmit the resident. Interviews with facility staff, including the Director of Nursing and the Nursing Home Administrator, revealed that the decision not to readmit the resident was based on the perceived danger the resident posed to themselves and others. However, the facility did not document any communication with the hospital regarding the resident's behavior at the time of discharge, nor did they follow the proper procedures for a facility-initiated discharge. The resident's legal guardian and the ombudsman were not informed of the specific behaviors that led to the decision, and the facility did not provide the required notice for discharge, resulting in a deficiency citation.
Failure to Provide Timely Fresh Water to Residents
Penalty
Summary
The facility failed to provide fresh water in a timely manner for several residents, as observed during a survey. On the morning of October 9, 2024, multiple residents were found with water cups that were dated from the previous night, indicating that they had not received fresh water since then. Resident R701 had an empty and warm water cup, and by midday, the same cup was still present without being refilled. R701 expressed that they never receive fresh water and that it is an ongoing issue. Similarly, R702's water cup was half full and warm, and they expressed a desire for fresh water, stating they would ask a CNA when they came into the room. R703 and R705 also had similar experiences, with warm water cups that had not been refreshed, and both residents expressed dissatisfaction with the lack of fresh water. The facility's policy on hydration states that fresh bedside drinking water should be available at all times unless contraindicated, and residents should be assisted to drink throughout the day. However, the observations and resident statements indicate that this policy was not being followed. CNA B mentioned that the water cart is usually cleaned and returned to the floor by 8:00 AM, and they try to pass water by lunchtime or earlier. Despite this, the Director of Nursing (DON) was unaware of any issues with residents receiving fresh water, suggesting a communication gap between staff and management regarding hydration needs.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain dignity and respect for a resident, identified as R704, who reported being verbally abused by a Certified Nursing Assistant (CNA C). During an interview, R704 recounted an incident where CNA C referred to their buttocks in a derogatory manner and mentioned that this was not the first occurrence of inappropriate behavior by CNA C. R704 had previously communicated these issues to the Unit Manager and the Wound Care Nurse (WC Nurse), expressing feelings of being dehumanized and requesting a transfer to another facility. The WC Nurse confirmed that R704 had reported CNA C's refusal to provide care and derogatory comments a couple of months prior, and stated that the behavior was reported to the Nursing Home Administrator (NHA). The Director of Nursing (DON) and NHA were made aware of the incident on the day it occurred, and CNA C was suspended and subsequently terminated following an investigation. R704, who was admitted with multiple fractures of the pelvis and required assistance with daily activities, was found to be alert and oriented, and had clearly articulated their needs and concerns about the verbal abuse and neglect they experienced.
Deficiency in Call Light Accessibility and Response
Penalty
Summary
The facility failed to ensure that call lights were functioning and within reach for two residents, leading to a deficiency. One resident, identified as R702, was observed without a call light cord, making it impossible for them to activate the call light. The resident, who has impaired cognition and requires assistance with activities of daily living, was unaware of how long they had been without a call light. A Certified Nursing Assistant (CNA) was unaware of the missing call light button until it was pointed out and subsequently replaced the cord, intending to notify maintenance. However, the call light was later found tucked under the resident's pillow, out of reach from their wheelchair. Another resident, R704, was observed with an activated call light that went unanswered for an extended period. Despite the resident's intact cognition and need for assistance with bed mobility and transfers, their call light remained on for over 20 minutes before an unknown staff member turned it off and informed a CNA of the resident's need for care. The Director of Nursing (DON) stated that call lights should be within reach and answered within 15 to 20 minutes, but was unsure if rounds were completed that morning to ensure compliance. The facility's policy emphasizes prompt response to call lights, which was not adhered to in these instances.
Sanitation Deficiency Due to Improper Linen and Trash Handling
Penalty
Summary
The facility failed to maintain a sanitary environment, potentially affecting all 129 residents. Observations made on multiple occasions throughout the day revealed various instances of dirty linen and trash being improperly stored or left unattended in resident rooms and common areas. Specific findings included a wheelchair with dirty clothing in the hallway, bags of dirty linen on floors and counters, and trash bags left in bathrooms, all contributing to a strong foul odor in some areas. These observations were consistent across different times, indicating a persistent issue with the handling and removal of soiled materials. Interviews with staff, including a CNA, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed discrepancies in the understanding and execution of responsibilities regarding the removal of dirty linen and trash. The CNA indicated that CNAs are responsible for removing linen and trash containing incontinence products, while housekeeping handles other trash. However, both the ADON and DON stated that CNAs should remove both linen and trash after providing care. The facility's policy on housekeeping and laundry emphasized the importance of regular collection and removal of soiled linen to prevent odor and infection control issues, but the observed practices did not align with these guidelines.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide scheduled showers for a resident diagnosed with Juvenile Rheumatoid Polyarthritis, who was dependent on staff for activities of daily living (ADL). The resident, who had intact cognition, was observed with a sign above their bed indicating a shower schedule of Monday and Thursday between 7 PM and 7 AM. However, the resident reported not receiving showers as scheduled and could not recall the last time they had one, suggesting it was in August. Documentation revealed that showers were marked as not applicable (N/A) on several dates in August and September. The Director of Nursing (DON) acknowledged that the resident had raised concerns about the timing of their showers, leading to a change from an afternoon to a day shift schedule. However, the staff member responsible for the resident's care continued to mark showers as N/A, mistakenly believing the resident was still on the afternoon schedule. The DON confirmed that the resident did not receive showers on the days marked N/A and explained that the staff should have verified the schedule change with a manager or the DON. The facility's policy on tub baths or showers did not address the specific concern raised in this incident.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide timely podiatry care for a resident, identified as R902, who was admitted with diagnoses including idiopathic peripheral autonomic neuropathy, chronic obstructive pulmonary disease, and type 2 diabetes mellitus with diabetic neuropathy. The resident reported experiencing pain due to long toenails, which made it difficult to wear shoes. Despite being admitted in October 2023, the resident was not seen by podiatry until August 2024, with a possible visit in April 2024 that could not be confirmed due to the absence of a treatment record. The facility's social worker confirmed that the resident was due for another podiatry visit in June 2024, which did not occur. The facility lacked a written policy and procedure for podiatry care, as confirmed by the social worker. The resident's electronic medical record showed a request for podiatry services in February 2024, a nursing note in July 2024 indicating the family's concern about the resident's toenails, and a physician order for podiatry services in March 2024. A second request for podiatry services was made in July 2024, and a podiatry visit finally occurred in August 2024. The facility's foot care policy emphasized the importance of regular foot inspections and documentation, particularly for diabetic residents, but these procedures were not adequately followed for R902.
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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