The Orchards At Lapeer
Inspection history, citations, penalties and survey trends for this long-term care facility in Lapeer, Michigan.
- Location
- 239 South Main Street, Lapeer, Michigan 48446
- CMS Provider Number
- 235654
- Inspections on file
- 24
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at The Orchards At Lapeer during CMS and state inspections, most recent first.
A resident with diabetes, neuropathy, osteomyelitis of the left ankle/foot, and a prior right BKA developed a swollen left ankle that was lanced by a practitioner, creating an open wound with drainage and an order for daily wound care. Imaging showed joint deformity, soft tissue edema, and air in the tissues, and subsequent wound assessments documented an in‑house–acquired lateral ankle wound with granulation tissue, undermining, mild subcutaneous emphysema, and apparent tendon exposure. However, nursing documentation showed no wound treatment orders for the ankle until a week after it was first lanced and only one documented dressing change thereafter, with no recorded monitoring of wound worsening. The DON acknowledged concerns about the lack of assessment, monitoring, and timely treatment, despite facility policies requiring consistent skin inspection and necessary wound care. The resident was later sent from an ortho appointment to the hospital, where extensive soft tissue gas, joint destruction, and necrotizing soft tissue infection were identified, resulting in emergent surgery and subsequent amputations.
The facility failed to submit required payroll-based journal (PBJ) direct care staffing data to CMS for an entire fiscal quarter. A review of the PBJ Staffing Data Report showed a triggered concern for failure to submit any data for the quarter, which should have included the type, number, and hours worked for clinical staff providing resident care. In an interview, the Administrator reported that the corporate office was responsible for sending the staffing documents and acknowledged that the information was not submitted, despite being aware of the quarterly CMS reporting requirement.
Surveyors found that the facility failed to provide adequate nursing staff and RN coverage, leading to resident reports of long call light response times, delayed ADL and toileting assistance, and cold meals. A group of residents described waiting up to an hour for call lights to be answered, staff turning off call lights without returning, and meal carts sitting in hallways for extended periods before trays were passed or feeding assistance provided. Individual residents with significant medical conditions and full cognitive abilities reported waiting 45 minutes in the bathroom for help, frequent hour-long waits for call light response, and inconsistent assistance on both day and night shifts. Review of posted Daily Staffing Reports showed they were not updated daily, did not consistently distinguish RNs from LPNs, and documented multiple days with very low nurse and CNA numbers, including nights with only one nurse for more than 60 residents and days with no RN listed. The DON and Administrator acknowledged nurse turnover, the DON’s frequent work on the floor for extended hours, and a missed PBJ staffing submission for an entire quarter, while staffing records for numerous days were missing or incomplete.
The facility did not maintain an up-to-date daily nurse staffing report. Surveyors found that the staffing list posted at the main entry was several days old, leaving residents, visitors, and staff without accurate, current information about which staff were on duty.
A resident with multiple serious conditions and documented Full Code status experienced a cardiac arrest and was found unresponsive and not breathing. Nursing staff initiated CPR, but confusion arose over whether the resident was Full Code or DNR after a nurse misinterpreted the code status form, leading to chaotic communication and multiple calls to 911 in which EMS was requested, cancelled, and later re-requested. When EMS arrived, staff were performing CPR, but the CPR backboard was improperly positioned, the crash cart drawers were unopened, and the AED on the cart had not been used. Review of records showed the resident’s EMR, physician orders, and care plan all indicated Full Code, while several nurses present lacked current AHA BLS for Healthcare Provider certification, and the facility had no specific CPR policy, resulting in a failure to provide basic life support consistent with the resident’s documented code status.
Two residents did not receive adequate and consistently monitored nutrition and hydration. One resident with severe cognitive impairment, multiple chronic conditions, and a respiratory infection had highly inconsistent and contradictory meal-intake documentation over several days, with missing meals, entries recorded before typical meal times, and no reliable record of whether three daily meals were provided, despite a care plan requiring staff to monitor and record intake. Another resident with DM and ESRD on hemodialysis left for early-morning dialysis without breakfast or a sack meal, sometimes did not receive an HS snack, and had dialysis communication forms repeatedly indicating no meal or snack sent, while care plans and task documentation lacked clear interventions or consistent records for HS snacks or pre-/post-dialysis nutrition.
The facility failed to maintain proper infection control practices, leading to cross-contamination. Staff were observed not performing hand hygiene or wearing PPE during resident care. Medical equipment, including glucose monitors and blood draw supplies, was improperly cleaned and stored, increasing infection risk. The DON confirmed that cleaning protocols were not followed.
The facility failed to treat residents with dignity, as staff used personal phones and ear buds during care, causing confusion and embarrassment. Residents reported feeling ignored and disrespected, particularly during off shifts and weekends. The DON acknowledged the issue, which violated the facility's policy against phone use in care areas.
A facility failed to accurately code a pressure ulcer on the MDS for a resident with multiple diagnoses, including congestive heart failure and major depressive disorder. The resident developed an unstageable pressure ulcer on the right heel, which was not documented in the MDS assessment. Interviews revealed that the ulcer began as a hematoma and was not coded due to an oversight by the MDS Nurse, despite the facility's policy requiring accurate assessments.
The facility failed to timely revise care plans for two residents, leading to inaccuracies. One resident's care plan did not reflect their DNR status, while another resident's pressure ulcer care plan was delayed. The Social Service Director and DON acknowledged the oversights, which were contrary to the facility's policy requiring timely updates.
A facility failed to maintain accurate orders and proper care for a resident's unused feeding tube. The resident, with full cognitive abilities, experienced redness and pain at the insertion site, and the tube was not routinely flushed. Documentation inconsistencies were noted, with outdated care plans still indicating tube feeding dependence. The Director of Nursing acknowledged the issues, highlighting a need for process improvements.
A facility failed to follow standards of practice for PICC line care for a resident, resulting in inadequate documentation and monitoring. The resident's PICC line dressing was not changed within 24 hours of admission, and subsequent changes were inconsistently documented. The facility lacked a specific policy for PICC line care, and the required measurements of the catheter were not recorded, leading to a deficiency in the administration of IV fluids.
Two residents in the facility experienced significant health issues due to failures in medication administration. One resident with epilepsy did not receive seizure medications, leading to increased seizures and hospitalization. Another resident with multiple health conditions missed doses of several medications due to unavailability. The facility's procedures for managing medication shortages were not followed, resulting in repeated instances of medications being on order or awaiting delivery without timely resolution.
The facility failed to provide meals and snacks according to the menu for several residents, resulting in incomplete meals and missing snacks. A resident did not receive rice, vegetables, or cake with their meal, while another's breakfast was missing several items. Two residents did not receive dinner rolls, and a group of residents reported not consistently receiving evening snacks. The Dietary Manager and DON were unaware of these issues, indicating a breakdown in meal and snack distribution processes.
A facility failed to provide fresh water to residents, as observed with a resident who had a Styrofoam cup dated from the previous day containing warm water without ice. Staff refilled cups throughout the day, but residents were found without fresh water at scheduled refill times. Residents expressed dissatisfaction with the use of Styrofoam cups and reported attempts by others to access water from the hallway cart, risking contamination.
The facility failed to label, date, and dispose of expired foods in both the walk-in and resident refrigerators/freezers, risking foodborne illness. Items like frozen zucchini, french onion dip, and hot dogs lacked expiration dates, while resident food items were found without identifiers or proper labeling. The dietary manager confirmed that dietary aides are responsible for these tasks, but the facility's policy for safe food storage was not followed.
A resident with multiple medical conditions experienced a change in condition, including shortness of breath and low oxygen saturation. Although a physician evaluated the resident and intended to order a chest x-ray and expectorant, these orders were not entered or carried out, and the resident did not receive the prescribed cough syrup. There was also no care plan addressing the resident's respiratory symptoms, and communication lapses between the physician and nursing staff contributed to the failure to provide appropriate care.
A resident with a history of multiple falls and significant medical conditions experienced repeated falls due to inadequate interventions and supervision. Despite being at high risk, the care plans were not consistently updated, and the falls were unwitnessed, leading to a femur fracture. The facility's policies on accidents and maintaining a safe environment were not effectively implemented.
The facility failed to develop and implement comprehensive care plans for three residents, resulting in potential unmet care needs. One resident lacked a care plan for oxygen use, another had no care plans for ADLs, Wanderguard, or hospice care, and a third resident's care plan did not include required PASARR evaluations.
The facility failed to ensure sufficient nursing staff, resulting in inadequate care and supervision. Residents reported long call light response times and insufficient assistance with daily activities. Staff interviews confirmed frequent understaffing, particularly during night shifts, leading to increased workloads and compromised resident safety. Specific incidents included a resident falling and subsequently dying due to insufficient staff on duty.
The facility failed to ensure proper labeling and secure storage of medical supplies and medications. Treatment carts were left unattended and unlocked, containing supplies for wound dressings and prescription treatments. Opened containers of wound packing strips, Eucerin cream, peroxide, eye drops, and urinalysis test strips were found without proper dating. Three controlled substances were discovered on the side of a medication cart, not properly disposed of as per facility policy.
The facility failed to ensure that residents, responsible parties, and staff had a clear understanding of the facility's binding arbitration agreement prior to signing it. Interviews revealed that residents did not fully understand the agreements, and some were not aware they had signed them. The Administrator admitted that several staff members presented the agreements without necessarily having received proper education on the subject.
The facility failed to follow Infection Prevention and Control standards for Transmission-Based Precautions, leading to expired hand sanitizer, improper PPE use, and staff confusion about resident precautions. A resident with multiple diagnoses had incorrect signage for precautions, and staff did not follow proper PPE protocols.
The facility failed to ensure a safe environment by not maintaining accessible call lights for residents and improperly storing an oxygen tank. Multiple residents with impaired cognition were found with call lights out of reach, and an oxygen tank was improperly stored in a cloth basket. These deficiencies led to residents' frustration and the potential for unmet care needs.
The facility failed to complete an annual Level II Evaluation for a resident with multiple mental health diagnoses, resulting in the potential for unmet emotional or mental health needs. The evaluation was completed but not sent to the facility, and the Social Service Director was unaware of the missing documentation.
The facility failed to develop and implement a baseline care plan within 72 hours of admission for a resident with multiple diagnoses, resulting in unmet care needs and social isolation. The resident was observed in a neglected state, and staff were unaware of the specific care needs due to the absence of a baseline care plan.
The facility failed to review and revise care plans for a resident with a history of falls and multiple medical conditions. Despite multiple falls and a significant injury, the care plans were not consistently updated with new interventions to prevent future falls, leading to continued falls and the development of pressure ulcers.
A resident with multiple diagnoses, including heart failure and diabetes, developed two facility-acquired pressure ulcers due to the improper fit of a left knee immobilizer and immobility. The facility failed to follow its policy on pressure ulcer risk assessment, leading to the development of Stage 2 pressure ulcers on the resident's left outer ankle and right outer heel.
A resident with multiple diagnoses had their PEG tube removal delayed due to transportation issues and miscommunication among staff, despite transitioning to an oral diet and gaining weight. The tube was not regularly flushed, and necessary supplies were often missing, leading to unmet care needs and feelings of hopelessness for the resident.
The facility failed to ensure proper communication and documentation of hospice services for two residents, resulting in the absence of progress notes, assessments, and care plans in the medical record. This led to incomplete medical records and potential gaps in the coordination of care for residents receiving hospice services.
The facility failed to ensure accurate and updated daily nurse staffing postings, resulting in discrepancies between posted and actual staffing hours. CNAs working in the office without direct care assignments were counted as direct care staff, and the BIPA program used for documentation had inaccuracies. Additionally, postings were not updated over weekends.
Failure to Assess and Provide Ongoing Treatment for Ankle Wound Leading to Severe Infection and Amputation
Penalty
Summary
The deficiency involves the facility’s failure to assess, monitor, and provide ordered wound treatment to a resident’s left ankle wound. The resident was admitted with multiple serious conditions, including acute osteomyelitis of the left ankle and foot, a non‑pressure chronic ulcer of the left lower leg, diabetes with neuropathy, and a prior right below‑knee amputation. On 1/20, the practitioner assessed a swollen left ankle, anesthetized the area, lanced it, and drained approximately 60 cc of serosanguinous fluid. An X‑ray was ordered, the resident was made non‑weight bearing, an immobilizer was ordered, a culture was obtained, and the resident was noted to already be on antibiotics. The wound care assessment from that date documented an open ankle wound with instructions to cleanse with wound cleanser, apply xeroform, and cover with kerlix or border foam, with dressing changes daily and as needed. Subsequent diagnostic results and assessments documented ongoing ankle pathology and an open wound, but nursing documentation did not reflect consistent wound care. On 1/21, an X‑ray showed deformity of the tibiotalar joint, diffuse soft tissue edema, and pockets of air collections in the soft tissues, with underlying cellulitis considered. On 1/23, a nursing progress note again described a swollen left ankle, lancing with purulent drainage, a culture (later reported as showing no organism detected), and an X‑ray indicating Charcot foot. A wound care assessment on 1/27 described Wound #2 on the left lateral ankle, acquired in‑house on 1/20, as an eroded open area at the aspiration site with white, pink‑yellow granulation tissue, fatty debris partially removed by sharp dissection, scant to moderate serous exudate, undermining from 11:00 to 3:00 up to 1.8 cm, mild subcutaneous emphysema, and apparent tendon exposure, but noted no signs of infection. Despite these findings, the Treatment Administration Record and orders showed that a specific order for daily dressing changes to the left ankle with Medi honey, ABD pad, and kerlix was not entered until 1/27, and only one dressing change was documented on 1/28. There were no documented dressing changes or wound treatments to the left ankle between 1/20, when the ankle was first lanced and became an open wound, and 1/27, when the wound care team reassessed it. Facility assessments and progress notes did not identify or document the worsening of the ankle wound during this period. The DON acknowledged concerns with the lack of assessment, monitoring, and timely treatment orders when the skin condition worsened, and facility policies required licensed nurses to consistently monitor skin, inspect and document breaks in skin, and ensure residents with ulcers receive necessary treatment and services to promote healing and prevent infection. A review of hospital records showed that when the resident was sent out from an orthopedic appointment to the hospital, imaging and clinical evaluation identified extensive gas in the soft tissues around the ankle, severe deformity, and findings concerning for necrotizing soft tissue infection. The ER physician documented infection on the lateral ankle with complete degeneration of the joint and purulent drainage, and the resident underwent emergent ankle disarticulation followed by a left below‑knee amputation and later a left above‑knee amputation, with postoperative diagnosis of necrotizing fasciitis of the left lower extremity.
Failure to Submit Quarterly PBJ Direct Care Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate payroll-based, direct care staffing information to CMS for the fourth fiscal quarter of 2025 (July 1–September 30), as required. A review of the Payroll Based Journal (PBJ) Staffing Data Report for that quarter showed a triggered concern labeled “Failed to Submit Data for the Quarter,” defined as no data submitted for the quarter. This PBJ data is intended to identify the type, number, and hours worked for clinical staff providing care to residents. During an interview, the Administrator stated that the corporate office was responsible for submitting the staffing documents to CMS and acknowledged that the information was not sent. The Administrator also confirmed awareness that submission of payroll-based direct care staffing data to CMS every quarter is required.
Inadequate Nursing Staff, RN Coverage, and Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nursing staff, including RNs, LPNs, and CNAs, to meet residents’ needs and to ensure required RN coverage, resulting in resident reports of long call light response times, delays in ADL assistance, and cold meals. During a confidential group interview with seven cognitively intact residents, all participants reported concerns with call light response, including waiting up to an hour for staff to respond, nurses not answering call lights, call lights being turned off without care being provided, and staff stating they would return but not doing so. The group stated these problems occurred at all times of day and were worse during shift changes. They also reported that staff frequently left the building to smoke, including CNAs who verbalized needing a cigarette after difficult care encounters, and that these concerns had been raised multiple times in Resident Council without resolution. Residents provided specific examples of unmet care needs related to inadequate staffing. One resident reported there were not enough staff to help during mealtimes, describing meal carts sitting in the hall for up to 40 minutes before trays were passed. Another resident described a roommate who needed help sitting up and with tray setup; the tray reportedly sat for about 45 minutes and was close to an hour before staff came in, by which time the food was believed to be cold. Another resident reported that their roommate required feeding assistance but staff were sometimes not available to provide this. Individual interviews corroborated these group concerns: one resident with heart failure, respiratory disorder, anemia, deep vein thrombosis, and hypertension, who was cognitively intact and dependent for transfers, toileting, dressing, and required maximum assistance with bathing, stated there were not enough people to answer call lights and expressed frustration with long waits for care. Another cognitively intact resident needing assistance with all care reported waiting 45 minutes in the bathroom for staff to answer a call light and believed food was cold when delivered due to insufficient staffing. A third cognitively intact resident needing assistance with all care reported multiple instances of long waits for call light response, sometimes up to an hour. A newly admitted resident who needed assistance with care stated that call lights were not always answered timely on both day and night shifts. Record review and staff interviews showed systemic issues with staffing levels, RN coverage, and required staffing documentation. The posted Daily Staffing Report near the front office was dated five days prior to the surveyor’s observation and was not updated daily as required. The DON reported that the corporate office was responsible for submitting PBJ staffing data to CMS and acknowledged that the facility’s PBJ report for the 4th fiscal quarter (July–September 2025) had not been submitted. The DON also stated that several nurses had left recently and in fall 2025, that many staff were working beyond 12-hour shifts and extra days, and that she herself frequently worked on the floor as a nurse, sometimes for 12-hour shifts and then again later the same day. The Administrator confirmed awareness that the PBJ report for the 4th quarter had not been submitted, acknowledged that the Daily Staffing Report was supposed to be updated daily but was not current, and agreed that some nurses had left and the DON was working many days on the floor. Further review of clinical staffing documents revealed missing Daily Staffing Reports and schedules for multiple days across several months, including days immediately prior to survey entry. Many Daily Staffing Reports did not identify whether nurses were RNs or LPNs and simply listed "Nurse" with counts for day and night shifts. On specific dates, documentation showed low numbers of clinical staff and lack of RN coverage, such as one nurse on night shift for over 60 residents, two aides on night shift for 68 residents, and days where only LPNs were listed with no RN identified. On one date, the schedule showed one night-shift nurse leaving at 2:00 a.m., leaving a single nurse alone for four hours. Multiple dates in late 2025 and early 2026 lacked any documented RN coverage on the Daily Staffing Reports. These documented staffing patterns, combined with resident reports of long call light response times, delayed ADL and toileting assistance, and delayed meal delivery, demonstrate the facility’s failure to ensure adequate nursing staff and required RN coverage to meet residents’ needs.
Outdated Daily Nurse Staffing Report Not Updated or Accessible
Penalty
Summary
The facility failed to provide an updated daily nurse staffing report as required. On 3/02/2026 at 9:05 AM, surveyors observed the DAILY STAFFING REPORT posted on the wall in the main entry and found it was dated 2/26/2026, making it four days out of date. As a result, residents, visitors, and staff did not have access to current information about which staff members were working on that day, because the only posted staffing list was outdated.
Failure to Follow Full Code Status, Timely Activate EMS, and Use AED During Cardiac Arrest
Penalty
Summary
The deficiency involves the facility’s failure to correctly identify a resident’s code status, promptly notify EMS, and use an available AED during a cardiac arrest event. The resident had multiple serious diagnoses, including metabolic encephalopathy, COPD, heart disease, PVD, epilepsy, dementia, kidney failure, anemia, and aphasia, and was severely cognitively impaired per the MDS, requiring assistance with all care. Documentation in the EMR, including a Code Status/Do Not Resuscitate Directive form, physician orders, and the care plan, all indicated that the resident was a Full Code, with instructions that the resident wished to receive CPR and other life-sustaining treatments. Despite this, when the resident was found unresponsive and not breathing, staff became confused about whether the resident was a Full Code or DNR. When the Code Blue was called, Nurse C began CPR based on her report sheet, which indicated Full Code, and the crash cart was brought to the room. Nurse D went to the nurses’ station to verify the code status and misinterpreted the documentation that stated “Full code by default,” leading to confusion among staff. During this time, a nurse aide overheard the misinterpretation and communicated to EMS that the resident was a DNR, resulting in cancellation of EMS response. Multiple staff interviews, including those of Nurse D, Nurse Aide E, the HR Manager, and a confidential witness, described the scene as hectic and chaotic, with uncertainty among staff about the resident’s code status and repeated calls to 911 in which staff alternately reported that EMS was needed, then not needed, and that the resident was a DNR before later stating he was a Full Code. EMS records and interviews confirmed that the facility first called 911 reporting an unresponsive resident, then cancelled the request, then called again to say EMS was not needed because the resident was DNR, and finally called back later stating the resident was a Full Code and deceased. When EMS arrived, they found staff performing CPR with a BVM in use, but the CPR backboard was placed under the lumbar area instead of the thoracic area, and the crash cart drawers had not been opened. The AED present on the crash cart had not been opened or applied to the resident, despite being available. Review of staff CPR credentials showed that not all nurses present had current AHA BLS for Healthcare Provider certification, and some had only standard or non–healthcare-provider CPR training without clear AED training. The facility also lacked a specific CPR policy, and the DON stated that nurses were expected to follow their training, which did not ensure consistent BLS for healthcare providers, including early AED use, during this emergent event. The facility’s own Advance Directives Policy stated that Full Code status meant the resident would receive full resuscitation and life-sustaining treatment, including CPR, and that Full Code status was indicated on the Code Status/Do Not Resuscitate Directive form. Despite this, staff did not consistently follow the documented Full Code status during the event. The combination of misinterpretation of code status documentation, delayed and inconsistent communication with EMS, failure to use the AED, and improper CPR technique as observed by EMS contributed to the deficiency related to providing basic life support, including CPR, prior to the arrival of emergency medical personnel, in accordance with physician orders and the resident’s advance directives.
Failure to Provide and Monitor Adequate Meals and Snacks for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate and accurately monitored nutrition and hydration for two residents, including one who became ill with a respiratory infection and another who received hemodialysis. For the first resident, who had a history of stroke, depression, anxiety, hypothyroidism, and severe cognitive impairment (BIMS 5/15) and required assistance with all care, the care plan identified a potential for altered nutrition and hydration and directed staff to monitor and record how much the resident ate. In December, this resident developed an excessive cough and was later assessed with a respiratory infection, with an x-ray and antibiotics recommended. Progress notes show that the resident was transferred to the ER for right leg weakness and possible stroke and was diagnosed with low sodium, low potassium, weakness, and dehydration, treated with IV fluids, and then returned to the facility. A detailed review of the electronic "Nutrition – Amount Eaten" task documentation for this resident from late December through early January revealed erratic and inconsistent charting that did not reliably capture meal intake. There were two separate intake documents with overlapping and contradictory entries, including multiple meals charted at the same time, meals documented before typical meal times, and conflicting percentages for the same time entry. On some days, only one meal was documented, and on other days there was no documentation at all, despite the resident being present in the facility and expected to receive three meals. Some entries were charted in batches and prior to meals, making it impossible to determine actual meal times or whether the resident received and consumed three meals per day. The registered dietitian reported she had last seen the resident in early December before the respiratory illness, had not reviewed the late December/early January intake documentation, and was unaware of the ER visit for low sodium, low potassium, and dehydration. For the second resident, who had diabetes, end-stage renal disease on hemodialysis, heart disease, anemia, depression, anxiety, and a humerus fracture, the facility failed to ensure that breakfast or snacks were provided in relation to early-morning dialysis treatments. This resident was cognitively intact (BIMS 13/15) and required assistance with care. A confidential interview indicated the resident left for dialysis around 4:45 a.m., returned mid- to late morning, and did not receive a meal or food before leaving, nor a sack lunch or food to take along. The same source reported that the resident sometimes did not receive an evening snack and could go from the evening meal until nearly lunchtime the next day without food, and that the resident sometimes had to ask for the evening snack and did not always receive it. Dialysis communication forms repeatedly showed "Meal/Snack Sent" as "None," "No," or left blank, and the dialysis center’s documentation showed snack intake of 0 on those days, except for one dialysis supplement. Further review of this dialysis resident’s records showed that the "Nutrition – HS Snacks" task documentation was not consistently completed, with multiple dates missing any record of whether a snack was taken and some dates marked "Not applicable." The resident’s care plans for diabetes, altered nutrition/hydration related to renal diet and fluid restriction, and hemodialysis three times weekly did not include interventions to provide HS snacks, pre-dialysis meals, or snacks/lunches to take to dialysis. The kitchen manager stated the resident left before the kitchen opened and that nothing was prepared the night before because she believed the resident did not want anything, but she did not know if this was true for each dialysis day. The registered dietitian stated sack lunches were available and believed the resident did not want one, and acknowledged that the care plan did not address nutrition from supper the night before dialysis through the time before or after breakfast, nor did it mention HS snacks. Overall, the documented practices and omissions show that the facility did not consistently offer or document meals and snacks necessary to maintain these residents’ nutrition and hydration as required by their conditions and care plans.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, leading to cross-contamination among residents. On multiple occasions, staff members were observed not performing hand hygiene or wearing appropriate Personal Protective Equipment (PPE) during resident care. For instance, a CNA assisted a resident with their meal, picked up a dropped pillow, and continued feeding without washing hands. Another CNA was seen performing incontinence care without a protective gown, despite enhanced barrier precautions being in place. Additionally, a nurse used a personal pulse oximetry machine on a resident and returned it to their pocket without cleaning it. Further observations revealed improper handling and cleaning of medical equipment. A nurse performed glucose monitoring in the hallway, placed the monitor on a medication cart, and returned it to a drawer without cleaning it. The nurse was unsure of the facility's policy on cleaning glucose monitors between resident uses. The Director of Nursing later confirmed that the monitors should be cleaned with disinfectant wipes after each use, but this practice was not followed. Additionally, blood draw equipment was left unsupervised on a treatment cart in the hallway, with capped needles and blood specimens exposed. The lab technician responsible for the equipment admitted to leaving it out and not securing it, which was against proper protocol. This lack of supervision and improper storage of medical equipment further contributed to the risk of cross-contamination and infection spread within the facility.
Staff Use of Personal Phones During Resident Care
Penalty
Summary
The facility failed to ensure that residents were treated in a respectful and dignified manner, as evidenced by staff using personal cell phones while in residents' rooms and during the provision of care. During an interview with a group of residents, it was reported that staff members were talking on personal phones and using ear buds, leading to confusion and embarrassment for residents who mistakenly believed the staff were speaking to them. This behavior was described as disrespectful and an invasion of privacy, with residents feeling ignored and upset when staff did not acknowledge them due to being engaged in personal calls. The Director of Nursing acknowledged the issue, noting it was more prevalent during off shifts and weekends when administration was not present. The facility's policy prohibits the use of personal cell phones in resident care areas to prevent privacy violations, yet this policy was not being adhered to. The residents expressed a desire for this behavior to stop, highlighting the ongoing nature of the problem and the impact on their dignity and privacy.
Failure to Accurately Code Pressure Ulcer on MDS
Penalty
Summary
The facility failed to accurately code a pressure ulcer on the Minimum Data Set (MDS) for a resident, identified as R44, who was admitted with multiple diagnoses including congestive heart failure, major depressive disorder, generalized anxiety disorder, and metabolic encephalopathy. During a record review, it was found that R44 had an unstageable pressure ulcer on the right heel, which was acquired at the facility. This pressure ulcer was not documented in Section M (skin conditions) of the quarterly MDS Assessment dated January 7, 2025. Interviews conducted with the wound care nurse and the Director of Nursing (DON) revealed that the pressure ulcer began as a hematoma on November 19, 2024, and later developed into an unstageable pressure ulcer. The DON confirmed that the MDS Nurse should have coded the pressure ulcer in the MDS assessment but was unsure why it was not done. The facility's policy on MDS Accuracy emphasizes the importance of accurate assessments by qualified staff, ensuring that the MDS reflects the resident's status accurately, and requires interdisciplinary team members to validate and certify the accuracy of the MDS.
Failure to Timely Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to revise care plans in a timely manner for two residents, resulting in inaccurate care plans. Resident #30, who is cognitively intact, had a signed physician's order for a Do Not Resuscitate (DNR) status, but the care plan inaccurately reflected a preference for full resuscitation. The Social Service Director, responsible for updating care plans related to code status, acknowledged the oversight and stated that the care plan had not been updated due to being busy with other updates. Resident #44, who has severe cognitive impairment, developed an unstageable pressure ulcer on the right heel, which was facility-acquired. The wound was identified on a specific date, but the care plan for wound management was not initiated until several days later. The Director of Nursing was unable to explain the delay, although the wound care nurse is typically responsible for updating care plans. The facility's policy requires care plans to be reviewed and revised as changes in the resident's care occur.
Deficiency in Feeding Tube Care and Documentation
Penalty
Summary
The facility failed to ensure accurate orders and proper maintenance for a feeding tube that was not being used for a resident. The resident, who had full cognitive abilities, was observed with a reddened and painful feeding tube insertion site, with dried red drainage present. The resident reported that the tube was not routinely flushed with water, and there was no equipment available in the room for flushing the tube. Despite the resident taking medications and food orally, the tube was scheduled for removal, but the orders still included instructions for flushing the tube with water during medication passes. The Medication Administration Record/Treatment Administration Record (MAR/TAR) showed inconsistencies in the documentation of tube flushing and care. Nurses documented that the tube was flushed with water on some occasions, while on others, it was noted as not flushed or refused by the resident. There was no additional documentation explaining the refusals or any contact with the provider. The care plan for the resident was outdated, still indicating dependence on tube feedings, despite the resident no longer receiving them. The facility's failure to update the care plans and ensure accurate documentation and care of the feeding tube led to the deficiency. The resident's complaints of discomfort and the presence of redness and drainage at the tube site were not adequately addressed, and the care plans did not reflect the resident's current status or needs. The Director of Nursing acknowledged the inaccuracies in orders and documentation, indicating a need for improvement in the facility's processes.
Failure to Follow PICC Line Care Protocols
Penalty
Summary
The facility failed to adhere to standards of practice for the assessment, monitoring, and dressing changes of a PICC line for a resident. The resident, who was admitted with a PICC line, did not have a baseline care plan initiated upon admission. The dressing for the PICC line was not changed within 24 hours of admission as required, and subsequent dressing changes were not consistently documented every 7 days as per the facility's protocol. Specifically, the dressing was documented as changed on 2/28/25, but not on 3/7/25, and there was no measurement of the PICC line documented during these changes. The Director of Nursing (DON) and a nurse confirmed the lack of documentation and adherence to the facility's standards of care, which were based on an external manual. The manual required the measurement of the external length of the catheter to ensure it had not migrated, but this was not documented in the resident's medical record. Additionally, the facility did not have a specific policy for PICC line care, and the admission assessment lacked documentation of the PICC line measurements. These oversights contributed to the deficiency in providing safe and appropriate administration of IV fluids for the resident.
Medication Administration Failures Lead to Resident Health Issues
Penalty
Summary
The facility failed to ensure the proper acquisition and administration of medications for two residents, resulting in significant health issues. Resident #34, who had a history of epilepsy and severely impaired cognition, did not receive prescribed seizure medications, including Fycompa, Briviact, and Zonisamide, on multiple occasions across January, February, and March 2025. This failure led to an increase in seizure activity, a fall, and subsequent hospitalization. The Director of Nursing (DON) acknowledged the delay in acquiring the medications and the lack of documentation regarding communication with the resident's neurologist. Resident #56, who had multiple diagnoses including end-stage renal disease and convulsions, also experienced medication administration failures. The resident's Sevelamer Carbonate, Amlodipine Besy-Benazepril, Donepezil, and Gabapentin were not administered as prescribed, with numerous doses missed due to unavailability. The Unit Manager (UM) was unaware of these issues and indicated that proper procedures for reordering medications were not followed, leading to the shortages. The facility's policy on medication shortages was not adhered to, as evidenced by the lack of timely communication with the pharmacy and failure to utilize emergency medication supplies. Documentation in the progress notes highlighted repeated instances of medications being on order or awaiting delivery, but there was insufficient action taken to resolve these shortages promptly. The report underscores the facility's systemic issues in managing medication orders and ensuring residents receive their prescribed treatments.
Failure to Provide Meals and Snacks as Per Menu
Penalty
Summary
The facility failed to provide meals according to the menu for four residents, resulting in incomplete meals being offered. Resident #24 was observed eating a lunch meal that lacked rice, vegetables, and cake, with the CNA unable to explain the absence of these items. Resident #1's breakfast meal was missing several items listed on the meal ticket, including a hash brown patty, egg, cereal, and muffin. The Dietary Manager was unable to provide a clear explanation for these omissions, indicating a lack of proper communication and documentation regarding resident preferences. Resident #26 did not receive a roll or dessert with their lunch meal, and another resident in the same room also complained about not receiving a roll. Similarly, Resident #17 did not receive a dinner roll with their meal. A review of the menu confirmed that these items were supposed to be included. A large container of uneaten dinner rolls was found in the dining room, and the Dietary Aide's response suggested a lack of attention to detail in meal distribution. Additionally, a group of residents reported not consistently receiving their evening snacks, with some staff and residents taking snacks intended for others. The Dietary Manager and DON were both unaware of the issue, indicating a breakdown in the process of distributing snacks. Resident #8 was also observed not receiving a roll or cake with their meal, as indicated on their meal ticket, and expressed dissatisfaction. The DON acknowledged the issue and planned to address it with the dietary department.
Failure to Provide Fresh Water to Residents
Penalty
Summary
The facility failed to ensure that residents received fresh fluids at their bedside in a timely manner, as observed with Resident #11 and other residents in the East hallway. Resident #11, who has a history of traumatic brain injury, dementia, seizure disorder, schizophrenia, and peripheral vascular disease, was found with a Styrofoam cup dated from the previous day, containing warm water without ice. The resident was unaware of when the water was last provided, indicating a lack of fresh water supply. Observations revealed that several residents had water cups dated from the previous day or undated, all containing warm water without ice, except for one resident who had a cup dated with the current date and ice. Staff member K was observed refilling water cups and stated that residents received a new cup each day at 2:00 PM, with refills occurring throughout the day. However, the Director of Nursing confirmed that the practice involved using the same Styrofoam cup for 24 hours, with refills scheduled at specific times. Despite this schedule, residents were found without fresh water at the designated refill time. Additionally, residents expressed dissatisfaction with the use of Styrofoam cups and reported instances of other residents attempting to access water and ice from the hallway cart, potentially leading to contamination. The facility's policy outlined a water pass schedule, but the observed practices did not align with ensuring fresh water availability for residents.
Failure to Properly Label and Dispose of Expired Foods
Penalty
Summary
The facility failed to properly label, date, and dispose of expired foods in both the walk-in refrigerator/freezer and the resident refrigerator/freezer, which could potentially lead to foodborne illness. Observations revealed that several items, including a bag of frozen zucchini squash, a can of french onion dip, and a package of hot dogs, lacked expiration or use-by dates. Additionally, a box of blueberries, tomatoes, celery, and a bag of onions were found with labels indicating they should have been used by specific dates. In the resident refrigerator/freezer, items such as jam, ice cream, popsicles, a jar of pickles, and a jug of oat milk were found without resident identifiers or proper labeling. The dietary manager confirmed these findings and stated that dietary aides are responsible for ensuring expired items are discarded and resident food is labeled and disposed of after three days. However, despite a cleaning schedule indicating that dietary staff were checking for expired items, the policy for safe storage and handling of outside food was not followed. This policy requires food brought in for residents to be labeled with the resident's name and the date it was brought in, and any food not consumed within three days should be discarded. The failure to adhere to these procedures was verified through interviews and record reviews.
Failure to Enact Physician Orders Following Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure that physician's orders were enacted for a resident who experienced a change in condition. The resident, who had a history of an enlarged heart, anxiety, depression, Barrett's Esophagus, GERD, and debility, was admitted with full cognitive abilities and required some assistance with care. The resident developed shortness of breath, low oxygen saturation, and was later transferred to the hospital, where he was diagnosed with pneumonia and other complications. The physician had evaluated the resident and documented a chief complaint of cough and chest congestion with brown sputum. During this visit, the physician intended to order a chest x-ray and start an expectorant, but there was no evidence in the medical record that these orders were entered or carried out. The resident already had an as-needed order for Guaifenesin cough syrup, but it was not administered. Additionally, there was no care plan addressing the resident's respiratory symptoms, cough, or congestion. Interviews with nursing staff and the physician revealed a lack of communication and follow-through regarding the physician's intended orders. Nurses were not aware of the chest x-ray order, and the physician typically rounded with the receptionist rather than nursing staff, leading to missed or uncommunicated orders. The absence of nursing assessments following the physician's visit and prior to the resident's acute decline further contributed to the failure to provide appropriate treatment and care according to the physician's orders and the resident's needs.
Failure to Prevent Falls and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure appropriate interventions and supervision to prevent falls for Resident #56, who had a history of multiple falls and significant medical conditions including heart failure, diabetes, and arthritis. Despite the resident's high fall risk, the care plans were not consistently updated with effective interventions after each fall. The resident experienced seven falls from September 2023 to April 2024, all of which were unwitnessed, and the interventions implemented were often basic and reactive rather than proactive. On 4/29/2024, Resident #56 was observed attempting to reach her lunch tray from a low bed position, indicating inadequate supervision and assistance. The resident's care plan included interventions such as keeping the bed in a low position and monitoring due to high fall risk, but these measures were insufficient to prevent further falls. The resident's falls occurred primarily in the late afternoon, evening, and night, yet there was no specific mention of increased supervision during these times. The facility's policies on accidents and incidents, as well as maintaining a safe environment, were not effectively implemented for Resident #56. The Director of Nursing and Administrator acknowledged the multiple falls and the need for better fall prevention strategies. However, the lack of timely and appropriate interventions contributed to the resident's repeated falls and eventual femur fracture, highlighting a significant deficiency in the facility's fall prevention and supervision practices.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, resulting in potential unmet care needs. Resident #217, who was admitted with diagnoses including weakness, anemia, hypertension, epilepsy, and obstructive sleep apnea, did not have a care plan in place for the use of oxygen despite a physician's order to start oxygen at 2L. The MDS Coordinator acknowledged the oversight in updating the care plan for the resident's oxygen use. Resident #221, admitted with diagnoses of hypertension, dementia, Alzheimer's disease, and rheumatoid arthritis, was observed with a Wanderguard on their foot without a care plan or rationale for its use. Additionally, there were no care plans for the resident's activities of daily living (ADLs) or hospice care, which was confirmed by the CNA and DON. The MDS Coordinator admitted that the care plans were missed and not communicated to the CNAs. Resident #4, admitted with diagnoses including delusional disorders, dementia, psychotic disorder, PTSD, and mood disorder, lacked documentation of the required Level II Evaluation and recommendations as per PASARR guidelines. The resident's care plan did not include a focus, goal, or interventions for the PASARR yearly evaluations or the need for Level II Evaluation, leading to a deficiency in meeting the resident's specialized mental health service needs.
Insufficient Nursing Staff Leading to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, resulting in multiple instances of inadequate care and supervision. Residents reported long call light response times and insufficient assistance with daily activities such as eating and toileting. For example, one resident indicated they did not receive help to eat and had their call light ignored, while another resident was found in bed without clothes and unable to reach their call light, which was on the floor. Staff interviews confirmed that the facility often operated with fewer nurses and CNAs than required, leading to delays in care and supervision. Confidential staff interviews revealed that the facility frequently had fewer nurses and CNAs than scheduled, particularly during night shifts. Staff reported that call-ins and no-shows were common, and positions were often not filled, resulting in increased workloads and compromised resident safety. One staff member indicated that they did not feel it was safe due to issues with falls, hospital transfers, and late medication passes. Another staff member reported that CNA's were often unable to complete incontinence care within the required two-hour intervals due to being short-staffed. Specific incidents highlighted the impact of insufficient staffing on resident safety. One resident fell and hit their head, resulting in significant bleeding and subsequent death. The investigation revealed that only two nurses were on duty at the time, instead of the usual three. Another resident expressed concerns about not receiving help after midnight, stating that call lights were often ignored for extended periods. A review of staffing assignments confirmed that the facility frequently operated below its ideal staffing levels, with discrepancies between posted and actual working hours for CNAs.
Failure to Ensure Proper Labeling and Secure Storage of Medical Supplies and Medications
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of medical supplies and medications. Observations revealed that treatment carts in the Main Hall area and near a specific room were left unattended and unlocked, containing supplies for wound dressings and prescription treatments. Additionally, laboratory supplies, including needles for blood draws, were not secured. Opened containers of wound packing strips, Eucerin cream, and peroxide were found without open dates or expiration dates. Eye drops and urinalysis test strips were also found opened without proper dating, and three controlled substances were discovered on the side of a medication cart, not properly disposed of as per facility policy. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the treatment carts should have been locked and that opened medical supplies should have been dated. The DON acknowledged that the eye drops should be dated with an open date and that wound packing strips should have an open date and discard date. The facility's policies on medication storage, administering medications, and discarding and destroying medications were reviewed, revealing that the facility did not adhere to its own policies, resulting in the potential for decreased efficacy of medications and supplies, drug diversion, and inaccurate medical results.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents, responsible parties, and staff had a clear understanding of the facility's binding arbitration agreement prior to signing it. During an entrance conference, the Administrator mentioned that arbitration agreements were offered on admission but were not mandatory to sign. However, the Business Office Assistant later provided a large stack of signed arbitration agreements, indicating that all residents had signed them. The arbitration agreements were found to be confusing, with references to a pharmacy that did not align with the rest of the document. Interviews with residents revealed that they did not fully understand the arbitration agreements, and some were not aware they had signed them. The Administrator admitted that several staff members presented the agreements without necessarily having received proper education on the subject, and no policy for arbitration agreements was provided upon request. Interviews with multiple residents confirmed that they did not have a thorough understanding of the arbitration agreements they had signed. One resident believed the agreement was about the right to refuse care, while another did not recall signing an arbitration agreement at all. During a resident council meeting, the group expressed confusion about what arbitration agreements were, with some remembering signing the agreement but not understanding it, and others having no recollection of it. The facility's failure to ensure proper explanation and understanding of the arbitration agreements led to residents and their representatives not being fully informed of their rights.
Infection Control Deficiency
Penalty
Summary
The facility failed to ensure Infection Prevention and Control standards of practice were followed for Transmission-Based Precautions (TBP). During a tour, it was observed that several rooms with Enhanced Barrier Precautions had expired hand sanitizer, and one was empty. Additionally, on the East hall, rooms with multiple residents had Contact Precautions signs without indicating which resident required the precautions, and there were no waste receptacles outside the doors for disposing of isolation gowns. Staff were observed entering and exiting rooms without using the necessary PPE, and there was confusion among staff about which precautions were in place for certain residents. Resident #44 was admitted with multiple diagnoses, including cellulitis, diabetes, sepsis, and a pressure ulcer. The resident had an order for Enhanced Barrier Precautions, but the sign on the door indicated Contact Precautions. Staff were observed entering the room without donning PPE, and there was no garbage available to dispose of PPE upon exiting the room. The nurse administering insulin to the resident did not follow proper PPE protocol and did not sanitize hands after removing PPE. A CNA was unaware of the need for PPE despite the Contact Precautions sign on the door. The Wound Care Nurse was also unsure about the correct precautions for Resident #44 and followed the incorrect Contact Precautions sign. There was no readily available garbage receptacle or hand sanitizer outside the room. The Director of Nursing confirmed that the resident should have been on Enhanced Precautions and not Contact Precautions, indicating a lapse in communication and proper signage. The incorrect sign was removed, and the correct Enhanced Precautions sign was posted, but staff confusion and improper PPE use were evident throughout the observations.
Inaccessible Call Lights and Improper Oxygen Tank Storage
Penalty
Summary
The facility failed to ensure a safe environment by not maintaining accessible call lights for residents and improperly storing an oxygen tank. Resident #4, who had severely impaired cognition, was observed multiple times with the call light on the floor and out of reach. The CNA acknowledged the issue and mentioned the call light had no clip, which was confirmed by the Unit Manager who promised to get a clip. Similarly, Resident #12, with moderately impaired cognition, had their call light clipped to a privacy curtain, making it inaccessible. The CNA later corrected this by clipping the call light to the bed within reach of the resident. Resident #24, who also had severely impaired cognition, was found in bed with the call light cord on the wall and the apparatus on the floor, making it unreachable. The resident expressed difficulty in reaching the call light and mentioned it did not work. This situation was not immediately addressed by the staff. Additionally, Resident #44 had a small oxygen tank improperly stored in a cloth basket on top of plastic bins. The DON confirmed that the tank should have been placed in a holder and not stored in such a manner. These deficiencies resulted in residents' frustration and the inability to call for assistance, potentially leading to unmet care needs. The observations and interviews with the residents and staff highlighted the facility's failure to maintain a safe and accessible environment for its residents, particularly concerning the accessibility of call lights and proper storage of medical equipment.
Failure to Complete Annual Level II Evaluation for Resident
Penalty
Summary
The facility failed to ensure that an annual review for mental disorder, intellectual disability, or a related condition was completed with Level II Evaluation documentation for one resident. Resident #4, who had diagnoses including delusional disorders, dementia, psychotic disorder, PTSD, and mood disorder, was admitted to the facility and was prescribed antipsychotic medication. The resident's medical record indicated that a Level II Evaluation was required by April 26, 2023, but no such evaluation was found in the resident's medical record for that period. An interview with the Social Service Director (SSD) revealed that the SSD was unaware of the missing Level II Evaluation and had not been in the role at the time the evaluation was due. Upon contacting the Coordinator for the Michigan Department of Health and Human Services, it was confirmed that the Level II Evaluation had been completed but was not sent to the facility. The facility's policy requires that all new admissions be screened for mental disorders, intellectual disabilities, or related disorders, and that the Level II Evaluation be included in the resident's medical record, which was not adhered to in this case.
Failure to Implement Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 72 hours of admission for a resident, resulting in the potential for unmet care needs and social isolation. The resident, who was admitted with diagnoses of hypertension, dementia, Alzheimer's disease, and rheumatoid arthritis, was observed in a state that indicated neglect, such as being dressed inappropriately and having a smell of urine in the room. Additionally, the resident had a Wanderguard placed without proper documentation or rationale, despite being assessed as low risk for elopement. Interviews with staff revealed that the Certified Nursing Assistant (CNA) and the Director of Nursing (DON) were unaware of the specific care needs of the resident due to the absence of a baseline care plan. The Minimum Data Set (MDS) Coordinator admitted that the care plans were missing from the resident's health record and that the information was not relayed to the CNAs. This lack of communication and documentation led to the resident not having care plans for Activities of Daily Living (ADL), Wanderguards, or hospice care, which are essential for providing appropriate care.
Failure to Update Care Plans Following Resident Falls
Penalty
Summary
The facility failed to review and revise care plans with resident changes to ensure necessary interventions for care and services were provided. Resident #56, who had a history of falls and multiple medical conditions including heart failure, diabetes, and arthritis, was observed struggling to reach her lunch tray from a low bed position. Despite multiple falls and a significant injury resulting in a fractured left femur, the care plans were not consistently updated with new interventions to prevent future falls. The care plans often included basic fall prevention strategies that were not initiated until after the resident had already fallen multiple times. The resident's care plans were reviewed and discussed with the Director of Nursing and the Administrator, revealing a lack of effective interventions to prevent falls. The facility's policy required comprehensive, person-centered care plans that reflect current standards of practice and are revised as the resident's condition changes. However, the care plans for Resident #56 did not meet these standards, as they were not adequately updated following each fall, leading to continued falls and the development of pressure ulcers due to improper fitting of a knee immobilizer and immobility.
Failure to Prevent Facility-Acquired Pressure Ulcers
Penalty
Summary
The facility failed to ensure that interventions were in place to prevent facility-acquired pressure ulcers for a resident, resulting in the development of two pressure ulcers. The resident, who had multiple diagnoses including heart failure, diabetes, and obesity, was admitted to the facility and later fell, fracturing her left femur. She returned to the facility with a left knee immobilizer, which was not properly assessed for fit, leading to a Stage 2 pressure ulcer on her left outer ankle. Additionally, the resident developed a Stage 2 pressure ulcer on her right outer heel due to immobility and pressure from lying in bed. The facility's records indicated that the resident's left ankle wound was first identified as a dark scab and later assessed as a Stage 2 pressure ulcer. There was no assessment for the right outer heel wound. Physician orders for heel boots and wound care were issued after the pressure ulcers had already developed. The facility's policy on pressure ulcer risk assessment was not adequately followed, as there was no order to ensure the proper positioning of the left knee immobilizer to prevent skin breakdown.
Failure to Remove and Maintain PEG Tube
Penalty
Summary
The facility failed to ensure the timely removal and proper maintenance of a Percutaneous Endoscopic Gastrostomy (PEG) tube for a resident diagnosed with Guillain-Barre syndrome, acute respiratory failure, dysphagia, heart failure, and hypertension. Despite the resident transitioning to an oral diet and gaining weight, the PEG tube remained in place due to transportation issues and miscommunication among staff. The resident expressed frustration and feelings of hopelessness over the delay in removing the PEG tube, which had been approved for removal by the physician in February 2024. Observations revealed that the PEG tube was not being flushed regularly, and necessary supplies were often missing from the resident's room. The resident reported that the tube had not been flushed for weeks at a time, and there was no dressing over the PEG tube site. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) indicated that the main reason for the delay was difficulty in arranging transportation for the removal appointment. The DON also mentioned that the resident's weights had not been stable, which was another reason for the delay. Record reviews confirmed that the resident's weight had been stable and had even increased since February 2024. The Registered Dietitian (RD) also confirmed that the resident's weight was stable and that they were comfortable with the PEG tube being removed. Despite multiple progress notes and physician orders recommending the removal of the PEG tube, the facility failed to schedule and follow through with the necessary appointment, resulting in unmet care needs for the resident.
Failure to Document Hospice Services
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for two residents, resulting in the absence of progress notes, assessments, and care plans in the medical record. Resident #221, who has been receiving hospice services since March 15, 2024, was observed on April 30, 2024, without any hospice care plans, treatment notes, or progress notes in the electronic health record (EHR). The Social Services Director and the Director of Nursing confirmed the absence of these documents and stated that the hospice company is responsible for faxing over the necessary information, which should then be scanned into the EHR. However, this process had not been completed for Resident #221, leading to a lack of essential documentation in the resident's medical record. Similarly, Resident #38, who began hospice services for lung and stomach cancer, had missing hospice notes from April 11, 2024, to May 5, 2024. During a tour of the facility, it was noted that the hospice nurse visited the resident weekly, but the corresponding notes were not present in the medical record. The Director of Nursing acknowledged the absence of these notes and stated that they would request the hospice notes to be sent over from the hospice service. The hospice nurse confirmed the resident's condition and the care provided, but the documentation was not included in the resident's facility medical record to ensure coordination of care. The facility's policy and the hospice company contract both emphasize the importance of communication and documentation between the hospice service and the facility. The lack of hospice care plans, treatment notes, and progress notes in the EHR for both residents indicates a failure to adhere to these guidelines, resulting in incomplete medical records and potential gaps in the coordination of care for residents receiving hospice services.
Inaccurate and Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the required posting of daily nurse staffing was accurate and updated, resulting in a lack of accurate documentation of daily staffing and a lack of accessible staffing information for all 62 residents, their representatives, staff, and visitors. The deficiency was identified through observation, interview, and record review. The Scheduler/CNA Supervisor admitted that CNAs working in the office without direct resident care assignments were counted in the postings as direct care staff. Additionally, the BIPA program used for documenting staffing hours had inaccuracies, such as misrepresenting partial shifts as whole shifts and not updating for call-ins or no-shows. On multiple occasions, the posted nursing staffing hours did not match the actual assignments. For example, on March 1, 2024, a CNA listed as working 8 hours had only worked 4 hours, and on February 26, 2024, a call-in was not updated, resulting in an inaccurate posting of 32 hours instead of 28 hours. Furthermore, the required postings were not updated over weekends, as observed on May 6, 2024, when the posting dated May 3, 2024, was still displayed. The Scheduler admitted that the postings were sometimes left on her desk and not updated during weekends, and the DON acknowledged the need for a system to ensure daily postings, even on weekends.
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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