The Orchards At Northwest
Inspection history, citations, penalties and survey trends for this long-term care facility in Detroit, Michigan.
- Location
- 16181 Hubbell St, Detroit, Michigan 48235
- CMS Provider Number
- 235539
- Inspections on file
- 22
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Orchards At Northwest during CMS and state inspections, most recent first.
A dependent resident with right-side hemiplegia, dementia, and other comorbidities, whose MDS, care plan, and Kardex all required a two-person assist for showering and rolling, was transferred by two CNAs via Hoyer lift to a shower bed, after which only one CNA remained to provide the shower. In a shower room with a narrow stall opening and raised threshold, the CNA asked the resident to roll so the resident’s bottom could be washed and rolled the resident away from their own body, contrary to facility bed-mobility policies that direct staff to roll residents toward them. The resident continued rolling, fell from the shower bed to the floor, and sustained a facial laceration requiring sutures and reported knee pain, while an LPN was called only after the fall occurred.
A resident with right-side hemiplegia, vascular dementia, and total dependence for bathing was care planned and documented on the Kardex and MDS as requiring two-person assistance for showers and use of a shower bed. One CNA assisted only with the Hoyer lift transfer, then left after the primary CNA declined further help, and the primary CNA proceeded to shower the resident alone. While washing the resident’s bottom, the CNA rolled the resident away from themselves on the shower bed, and the resident continued rolling off the bed onto the floor, sustaining injuries. Interviews with the SDC and leadership and review of training logs showed there was no classroom training on shower-bed use, no documented training on bed mobility or positioning during showers, and no evidence that CNAs were trained to roll dependent residents toward them, despite facility policies describing that technique.
The facility's kitchen had multiple sanitation and maintenance deficiencies, including soiled surfaces, ineffective sanitizing solutions, and improperly cleaned and dried pans. Observations revealed issues such as a leaking garbage disposal, a non-functional sink faucet, and missing floor tiles, all of which failed to meet the 2013 FDA Food Code standards.
The facility failed to implement an effective QAPI program, as the NHA identified issues with customer service and resident smoking policy adherence but lacked objective data and analysis to address these concerns. The facility's QAPI policy requires data collection and analysis, which was not followed, and no additional documentation was provided during the exit conference.
The facility failed to maintain a comprehensive infection control program due to a lack of leadership and documentation from August to September 2024, increasing the risk of infection spread. Additionally, clean environmental services equipment was improperly stored in the soiled laundry area, as confirmed by staff, further compromising infection control efforts.
The facility failed to maintain a continuous Antibiotic Stewardship Program, leading to potential unnecessary medication use and antibiotic resistance. The Director of Nursing, who took over the infection control program in August 2024, confirmed the absence of documentation for the program from August to September 2024. Despite discussions in morning meetings, there was no documented evidence of antibiotic use, dosage, or monitoring, violating the facility's policy on Infection Prevention and Antibiotic Stewardship.
The facility failed to maintain continuity in the role of Infection Control Preventionist (ICP) and did not ensure the ICP completed necessary training, leading to potential knowledge deficits and delays in infection control data collection. The DON took over the role in August 2024 after the previous IP resigned, but did not complete the required training until November 2024, leaving a gap in infection control program documentation.
The facility did not screen residents for COVID-19 vaccine eligibility, provide education, or offer the vaccine, resulting in residents not receiving immunization. The DON revealed no documentation of a COVID-19 vaccine program and stated that an outside company previously handled vaccinations but was no longer available. The facility's policy for COVID-19 immunization was not provided.
The facility failed to provide adequate personal care for several residents, resulting in unmet needs. A resident was found with long, dirty fingernails and matted hair, while another had significant plaque buildup on their teeth and an unkempt appearance. Despite requiring assistance, there was no documentation of care refusal, and care plans lacked specific instructions. Additionally, a resident was found lying in urine multiple times, indicating a failure to provide timely incontinence care.
The facility failed to maintain RN coverage for eight consecutive hours daily, as required, due to staffing issues, particularly on weekends. This deficiency was confirmed by the staffing coordinator and DON, affecting all 120 residents.
The facility's second floor had several maintenance deficiencies, including a soiled elevator exhaust fan, scuffed and dingy paint, exposed nails on a handrail, and missing flooring in day rooms. These issues affected all residents on the floor and those using the elevator. The Director of Maintenance acknowledged the problems, and the Nursing Home Administrator agreed that maintenance is an ongoing process, but a maintenance checklist was not provided.
The facility failed to provide annual dementia management and abuse prevention training for three CNAs, as required. Records for CNAs H, I, and J showed no evidence of the necessary training within the specified time frames. Interviews with the Staff Educator and DON confirmed the absence of training records, despite the facility's policy requiring 12 hours of annual training for CNAs.
A resident was found with their arm wedged between the bed and the wall, unable to reach the call button clipped to their pillowcase, resulting in unattended pain. An LPN confirmed the situation and assisted the resident. The DON acknowledged the call light should have been within reach, but no additional information was provided during the exit conference.
A facility failed to complete an Advance Directive for a resident with impaired cognition and multiple diagnoses, including heart disease and dysphagia. Despite attempts by the social worker to obtain a signed document from the guardian agency, the Advance Directive was not returned. The DON noted that the document should have been reviewed during care conferences, which occurred twice since the resident's admission, but it remained unsigned.
A resident with a history of serious medical conditions was found with bloody urine, which was reported to the nursing staff but not followed up with physician notification or further assessment. The facility's policy on acute changes in condition was not adhered to, leading to a potential delay in care.
A facility failed to report an injury of unknown source for a resident in a timely manner, resulting in a delayed investigation. The resident, who had severe cognitive impairment, complained of pain in the lower extremities, and an LPN observed a bruise but did not report it to the DON or NHA. The facility's policy required immediate reporting of such findings, but the NHA was only informed of the fracture by the hospital days later.
A facility failed to develop a comprehensive care plan for a resident with a tracheostomy. The resident, who had acute respiratory failure, laryngeal cancer, esophageal cancer, and tracheostomy status, was observed with a tracheostomy tube. The DON confirmed the absence of a care plan for tracheostomy care, which should have included care instructions and monitoring guidelines. No additional information was provided during the exit conference.
A resident's room contained hazardous objects, including a sharp metal screw protruding from a detached closet door and a bed bumper with protruding screws. The resident, who had severe cognitive impairment and required assistance with daily activities, expressed concern about potential injury. Maintenance staff confirmed the safety hazard, but repairs were not documented in the TELS system. The facility's maintenance policy was not followed.
A resident with severe cognitive impairment and dependent on a feeding tube was not properly monitored for weight fluctuations, despite being at high risk for weight loss. The facility failed to record accurate readmission and weekly weights, as required by policy, leading to potential undetected nutritional compromise.
The facility failed to provide necessary emergency tracheostomy supplies for a resident and did not consistently follow physician orders for tracheostomy care for another resident. Emergency equipment was missing from a resident's room, and trach care was not performed as ordered, with multiple instances of missed care documented.
A resident with a stoma was found to have expired medical supplies in their room, including heat and moisture exchangers and stoma caps. The DON acknowledged that these expired supplies should not have been stored with unexpired ones and should have been removed to prevent use. The resident had a history of cancer and an artificial larynx, with intact cognition.
A resident's privacy was compromised due to broken window blinds that were not repaired, resulting in feelings of disrespect and potential exposure during care. The resident, who requires significant assistance with daily activities and has multiple health conditions, expressed dissatisfaction with the situation. Interviews revealed that the nursing staff was responsible for notifying maintenance about repairs, but the facility's policy was not followed, leading to the deficiency.
The facility failed to implement proper hand hygiene and glove use during wound care for a resident and did not provide the proper receptacle for the disposal of PPE for another resident. A wound nurse did not follow hand hygiene protocols, and a resident's isolation room lacked an appropriate trash receptacle for PPE disposal, both of which were acknowledged by the DON as against the facility's policies.
A resident with severe cognitive impairment was found restrained in bed with garbage bags, a gown, and a sheet, without any orders, consents, or care plans. The CNA responsible claimed it was to prevent choking, but the facility's policy prohibits such restraints without proper documentation and consent.
A resident with severe cognitive impairments was found restrained with a plastic bag, a gown, and a sheet by a CNA, who claimed it was to prevent choking. The incident was reported internally but not to the State Agency, as required by the facility's policy. The facility is a restraint-free building, and the restraints used were not approved.
A facility failed to provide an armrest on a resident's wheelchair, resulting in the resident falling and sustaining a large hematoma. The resident, with a history of falls and impaired cognition, was sent to dialysis with only one armrest. The CNA admitted to not attaching the second armrest, and the DON confirmed the expectation for both armrests to be intact during transport. No specific policy was provided to ensure proper equipment assembly before transportation.
Failure to Provide Two-Person Assist and Safe Positioning During Shower Leading to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide the required two-person assistance during a shower and to safely reposition a dependent resident, resulting in a fall from a shower bed and injury. The resident had a history of right-side hemiplegia following a stroke, diabetes mellitus with diabetic retinopathy, dysarthria, aphasia, vascular dementia, and seizure disorder, and was unable to complete a BIMS interview. The resident’s MDS and care plan documented total dependence for showering/bathing and rolling in bed, with the need for assistance from two or more helpers, and the Kardex specified a two-person assist when showering and using the shower bed. Despite these documented needs, only one CNA provided the shower at the time of the incident. During the incident, two CNAs used a Hoyer lift to transfer the resident onto a shower bed, but only one CNA remained to perform the shower. The CNA who provided the shower reported that they were alone in the shower room and did not believe additional help was needed. While washing the resident, the CNA asked the resident to roll to the right side so the resident’s bottom could be washed and demonstrated rolling the resident away from their own body. The resident continued rolling and fell off the shower bed onto the shower floor. The LPN, who was not present during the shower, was called afterward and found the resident screaming and bleeding from the head, and emergency services were contacted. Post-incident observations and interviews further described the environment and staff practices that preceded the fall. The shower room had a narrow opening into the shower stall, with the shower bed only able to fit partway into the stall and a raised threshold at the entrance. The resident later reported having been on the shower bed, rolling over, and falling to the floor, and indicated ongoing pain in the right knee area. Staff interviews revealed that CNAs were expected to obtain care information from the Kardex and that there was no classroom training on the use of shower beds. The staff development coordinator stated that staff should roll residents toward themselves during care, and facility policies on bed mobility and turning a dependent resident directed staff to roll residents toward the staff member, but the CNA involved in the incident rolled the resident away from themselves while working alone, contrary to the resident’s documented need for two-person assistance.
Failure to Train CNAs on Safe Shower-Bed Positioning and Required Two-Person Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure CNAs had appropriate training and competencies in repositioning techniques and shower-bed care, which led to a resident rolling off a shower bed and sustaining injuries. The resident had a history of stroke with right-side hemiplegia, diabetes mellitus, diabetic retinopathy, dysarthria, aphasia, vascular dementia, and seizure disorder, and was totally dependent for bathing/showering per the MDS, requiring assistance of two or more staff. The resident’s care plan and Kardex both specified two-person assistance when showering and using the shower bed, and that the resident was totally dependent for transfers. Despite these documented needs, the resident reported being assisted by only one staff member during the shower when they rolled off the shower bed onto the floor. Surveyor interviews and record review showed that on the day of the incident, one CNA (CNA B) assisted another CNA (CNA C) only with the Hoyer lift transfer, then left, after CNA C declined further help with the shower. CNA C confirmed they were alone in the shower room while providing the shower. CNA C stated they rolled the resident onto their right side, away from themselves, to wash the resident’s bottom, and the resident “kept rolling,” ultimately falling from the shower bed to the floor. CNA C acknowledged that they obtain resident care information by reading the Kardex at the beginning of the shift and that they did not receive specific training on whether to roll residents toward or away from themselves during care, stating that their technique “depends on what I’m doing.” Further interviews with the Staff Development Coordinator and facility leadership revealed that staff did not receive classroom training on the use of shower beds, and the Staff Development Coordinator stated they did not provide training on bed mobility or positioning during showers/bed baths, believing it to be “common sense” and that CNAs should follow the Kardex. The ORMI/Annual Tracking Log for CNA in-services did not show training on bed mobility, Kardex training, or shower bed training. The DON acknowledged that, according to the MDS, care plan, and Kardex, two staff should have assisted with bathing and that the resident should have been rolled facing the CNA, consistent with facility policies on bed mobility and turning a dependent resident toward staff, which instruct staff to roll residents toward them. The facility did not have a specific policy for shower beds, and the DON and NHA were unable to provide evidence that the CNAs involved had been trained on shower bed use and proper positioning after the accident.
Kitchen Sanitation and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper sanitation standards in the kitchen, as observed during a survey. Several issues were noted, including visibly soiled surfaces such as a dust-covered disk above the handwashing sink and a dirty trash can lid. The floor in the dish tank machine area had chipped or missing tiles, making it difficult to clean. Additionally, food splatters were observed on the backsplash of the dishmachine, and these remained uncleaned during a follow-up visit. The garbage disposal was leaking, and the sanitizing solution used in the kitchen was found to be ineffective, testing below the required concentration. Further observations revealed that pans in the storage area were not properly cleaned and dried before being stacked, with some containing food debris. The stove's drip pan was also soiled with burnt food debris. The sink faucet in the cook's prep area did not shut off completely, and several floor tiles were missing in the dry food storage room, exposing surfaces that were not easily cleanable. These deficiencies were identified as not meeting the standards set by the 2013 FDA Food Code, which requires equipment and surfaces to be clean and sanitized, and floors to be smooth and easily cleanable.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the lack of objective data collection and analysis regarding identified areas of concern. During an interview, the Nursing Home Administrator (NHA) acknowledged issues with customer service and adherence to the resident smoking policy, noting that staff were not consistently speaking to residents in a professional manner and that residents were keeping smoking paraphernalia on their persons and smoking unsupervised. Despite recognizing these issues, the NHA was unable to provide any objective data or analysis to support the identification of trends or the effectiveness of any performance improvement plans. The facility's policy on Quality Assurance Performance Improvement, dated January 2019, outlines the responsibilities of the QAPI committee, including the identification and response to quality deficiencies, development and implementation of corrective actions, and monitoring of performance goals. However, the facility did not adhere to these guidelines, as there was no evidence of data collection or analysis to measure the situation or track improvements over time. During the exit conference, neither the NHA nor the Director of Nursing provided additional documentation or information to address the deficiency.
Inadequate Infection Control Program and Improper Storage of Clean Equipment
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program, as evidenced by the lack of documentation and operationalization of the program from August 10, 2024, through September 30, 2024. The Director of Nursing (DON), who assumed the role of infection control leader in August 2024, confirmed that the program was not executed due to the resignation of the previous Infection Preventionist (IP) and the unsuccessful hiring of a new IP in September. This resulted in a lack of accurate infection control tracking, surveillance, and data monitoring, increasing the potential for the spread of infections among residents. Additionally, the facility failed to properly store environmental services equipment, as observed on January 7, 2025. Clean items such as rags, mop heads, and towels were stored in the soiled laundry area, where items are placed into washing machines. The Laundry Aid (LA) and Head of Laundry (HL) acknowledged the improper storage and confirmed that clean items should not be stored in areas designated for soiled articles. This improper storage practice further compromised the facility's infection control efforts.
Failure to Maintain Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain a continuous Antibiotic Stewardship Program, which resulted in the potential for unnecessary medications and antibiotic resistance. The deficiency was identified during a review of the facility's infection control program with the Director of Nursing (DON), who had been overseeing the program since August 2024. The review revealed that there was no documentation of an infection control program from August 10, 2024, through September 30, 2024. The DON confirmed that the previous Infection Preventionist (IP) resigned in early August 2024, and although another IP was hired in September, it did not work out. During this period, the facility lacked documented evidence of resident antibiotic use, including the indication of use, dosage, duration of treatment, or monitoring of symptoms. The facility's policy on Infection Prevention and Antibiotic Stewardship was not effectively implemented. The policy outlined the need for written antibiotic use protocols, periodic reviews of antibiotic use, and feedback reports on antibiotic use and resistance patterns. However, the facility did not have a system in place to monitor antibiotic use or provide feedback reports. The DON mentioned that discussions about residents on antibiotics occurred during morning meetings, but there was no documented evidence to support these discussions. This lack of documentation and oversight led to the deficiency in maintaining an effective Antibiotic Stewardship Program.
Inadequate Infection Control Leadership and Training
Penalty
Summary
The facility failed to ensure continuity of care for the role of an Infection Control Preventionist (ICP) and did not ensure that the ICP completed specialized training in infection prevention and control. This resulted in potential knowledge deficits regarding current infection prevention and control standards, undetected outbreaks due to inadequate infection control surveillance, and delays in infection control data collection and summary. The Director of Nursing (DON) has been performing as the facility's designated infection control leader since August 2024, following the resignation of the previous Infection Preventionist (IP) in early August 2024. A review of the facility's infection control program revealed no documentation of an infection control program from August 10, 2024, through September 30, 2024. The DON confirmed that they did not complete the Nursing Home Infection Preventionist Training Course until November 18, 2024, and there was no one else in the facility who completed the required training from August 2024 to November 17, 2024.
Failure to Provide COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to screen residents for eligibility to receive the COVID-19 vaccine and/or booster, provide education regarding the COVID-19 vaccine and/or booster, and offer the COVID-19 vaccine and/or booster. This resulted in residents not receiving the COVID-19 immunization, potentially decreasing their protection from the SARS-CoV-2 virus and increasing the risk of serious illness and complications. During a review of the facility's infection control program with the Director of Nursing (DON), it was revealed that there was no documentation of an infection control program related to COVID-19 vaccines and/or boosters. The DON stated that no one in the facility had received the vaccine and that an outside company previously provided education and administered vaccines, but was no longer available in Michigan. The DON mentioned the possibility of calling a pharmacy for vaccines but could not explain why residents had not been offered or administered COVID-19 vaccines prior to the recertification survey. The facility's policy for COVID-19 immunization for residents was requested but not provided.
Failure to Provide Adequate Personal Care and Hygiene
Penalty
Summary
The facility failed to provide adequate personal care and assistance with activities of daily living (ADLs) for several residents, resulting in unmet needs. Resident R2 was observed with long, dirty fingernails, matted hair, and crusty residue on the lips and eyes, indicating a lack of personal hygiene care. Despite being scheduled for showers twice a week, R2's condition suggested that these were not being consistently provided. The Director of Nursing (DON) confirmed that such care should be part of daily routines, yet was unaware of R2's condition. Resident R108 was noted to have significant plaque buildup on their teeth and an unkempt appearance, with an odor emanating from their mouth. Despite requiring assistance with personal hygiene, there was no documentation of care being refused, and the care plan did not include specific instructions for bathing or oral care. The DON acknowledged that all residents should receive morning care, but R108's condition indicated this was not happening. Resident R112 was observed with thick, scruffy facial hair and appeared disheveled, despite requiring substantial assistance with personal hygiene. There was no record of care refusal, and the DON stated that any refusal should be reported. Additionally, Resident R49 had long, discolored nails with dark matter underneath, and Resident R51 was found lying in urine on multiple occasions, indicating a failure to provide timely incontinence care. The facility's policies on ADLs and personal hygiene were not being followed, as evidenced by the observations and interviews conducted.
Inadequate RN Coverage in Facility
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week, which is a requirement for adequate coordination of care. This deficiency was identified through interviews and record reviews, revealing that there was no RN coverage on multiple dates across October, November, and December 2024. The staffing coordinator acknowledged the lack of RN coverage, particularly on weekends. The Director of Nursing (DON) confirmed the inconsistency in RN weekend coverage, despite the expectation of having 8-hour RN coverage every day. The facility's policy on staff scheduling emphasizes the need for adequate staffing and RN coverage, which was not met, potentially affecting all 120 residents in the facility.
Deficiencies in Environmental Maintenance on Second Floor
Penalty
Summary
The facility failed to maintain a clean and safe environment on the second floor, affecting all residents residing there and those using the elevator. During an environmental tour, several deficiencies were noted, including a soiled exhaust fan in the elevator, scuffed paint on the pantry door, and dingy, scratched paint in the hallways. Exposed nails were found on a handrail between the soiled and clean linen rooms, and multiple resident room doors had scuffed paint. Additionally, missing flooring was observed in the east day room, and the west day room had missing and peeled paint at the baseboard. The entire second floor had scuffed and peeled paint on the handrails. The Director of Maintenance acknowledged these issues, and the Nursing Home Administrator agreed that cleaning and maintenance are ongoing processes, but a maintenance checklist was not provided by the survey exit.
Deficiency in Annual Training for CNAs
Penalty
Summary
The facility failed to ensure that three Certified Nurse Assistants (CNAs), identified as H, I, and J, received their required annual training in dementia management and abuse prevention. This deficiency was discovered during a review of the in-service training records for five CNAs. The records for CNAs H, I, and J did not show any evidence of the required training within the specified time frames. CNA H, hired on 5/28/2004, had no record of such training from 5/28/24 to 6/28/24. Similarly, CNA I, hired on 5/17/2016, lacked documentation of the training from 5/17/23 to 5/17/24, and CNA J, hired on 6/21/2010, had no record of the training from 6/21/23 to 6/21/24. Interviews with the Staff Educator and the Director of Nursing (DON) confirmed the absence of training records for these CNAs. The Staff Educator, who assumed the position in September 2024, acknowledged the limited availability of staff education records. The DON confirmed that CNAs are expected to complete annual training in abuse and dementia management to ensure adequate resident care. The facility's policy mandates that CNAs receive at least 12 hours of training annually, and those who do not meet this requirement are to be removed from the schedule until the training is completed. However, the records did not reflect compliance with this policy for CNAs H, I, and J.
Resident Unable to Reach Call Button, Resulting in Unattended Pain
Penalty
Summary
The facility failed to ensure that a call button was within reach for a resident, resulting in the resident not having a method to request assistance when needed. On January 6th, a resident was observed awake and lying in bed with their right arm wedged between the bed and the wall, indicating they were in pain and unable to free their arm. The resident's call light was clipped to their pillowcase, and they were unable to reach it with their left arm. A Licensed Practical Nurse confirmed the situation and assisted in freeing the resident's arm. The Director of Nursing later acknowledged that the call light should have been placed within the resident's reach. During the exit conference, the Nursing Home Administrator and Director of Nursing did not provide additional documentation or information regarding this concern.
Failure to Complete Advance Directive for Resident
Penalty
Summary
The facility failed to ensure an Advance Directive was completed for a resident, identified as R14, which resulted in the potential for inaccurate life-sustaining measures or withholding medical treatment. R14 was admitted with diagnoses including Candidiasis, Atherosclerotic Heart Disease, Benign Prostatic Hyperplasia, Dysphagia, and Myocardial Infarction. The resident had impaired cognition with a Brief Interview for Mental Status (BIMS) score of 4/15 and required extensive assistance with activities of daily living. Despite the social worker's attempt to obtain a signed Advance Directive from the guardian agency at the time of admission, the document was not returned. The Director of Nursing noted that the Advance Directive should have been reviewed during care conferences, which occurred twice since the resident's admission, but the document remained unsigned.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, identified as R65, who was observed with approximately 550 milliliters of red-colored urine in a urinal. R65, who had been admitted with diagnoses including candidal sepsis, enterocolitis due to C-Diff, chronic kidney disease stage 5, and hypertension, reported the presence of blood in the urine to the nursing staff the previous night. Despite the resident's intact cognition and the facility's care plan interventions to observe and report signs of infection, there was no documentation of assessment, monitoring, or physician notification in the electronic health record. Interviews with the resident and staff revealed that the midnight nurse was aware of the bloody urine, but no follow-up actions were taken, and the physician was not notified. The resident expressed fear due to the lack of response, and the urine cleared up on its own without medical intervention. The Unit Manager and Director of Nursing were unaware of the situation until informed later, and the facility's policy on acute changes in condition, which requires communication of symptoms to the physician, was not followed.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to ensure timely reporting of an injury of unknown source for a resident, leading to a delayed investigation. On 10/4/24, a resident, identified as R125, complained of bilateral lower extremity pain, prompting an order for a stat x-ray. The x-ray results showed no recent fracture or dislocation, but the resident continued to experience pain and swelling, leading to further tests and eventual transfer to a local hospital. On 10/7/24, the hospital informed the Nursing Home Administrator (NHA) that the resident had a fracture. The investigation concluded that the origin of the injury could not be identified, and staff interviews did not yield any viable results. The deficiency was further highlighted by the failure of a Licensed Practical Nurse (LPN) to report the observation of a bruise on the resident's leg, which was a potential indicator of a fracture. The LPN noted the resident's pain and administered acetaminophen but did not notify the Director of Nursing (DON) or the NHA about the bruise. The facility's policy required staff to report all allegations of abuse, neglect, and misappropriation of property immediately to the Administrator. The NHA and DON confirmed that they were not notified of the bruise or pain, which was against the facility's policy for reporting changes in a resident's condition.
Failure to Develop Comprehensive Tracheostomy Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a tracheostomy. The resident, identified as R175, was observed awake and lying in bed with a tracheostomy tube secured around his neck. The clinical record for R175 indicated an admission date and diagnoses including acute respiratory failure with hypoxia, laryngeal cancer, esophageal cancer, and tracheostomy status. On review, the Director of Nursing confirmed that a comprehensive care plan addressing tracheostomy care had not been developed for R175. This care plan should have included instructions on how to care for the tracheostomy and what to monitor. During the exit conference, no additional documentation or information was provided by the Nursing Home Administrator or Director of Nursing.
Failure to Remove Hazardous Objects from Resident's Room
Penalty
Summary
The facility failed to remove broken and hazardous objects from a resident's room, resulting in a potential safety risk. During an observation, a long sharp metal screw was found protruding from a detached closet door leaning toward the resident's bed. Additionally, a detached bed bumper with multiple protruding screws was observed against the wall behind the resident's bed. The resident, who was alert and able to be interviewed, expressed concern about the door potentially falling and causing injury. The resident had been admitted with several medical conditions, including anoxic brain damage, epilepsy, and a history of repeated falls, and required assistance with activities of daily living due to generalized weakness. The maintenance staff confirmed that the broken closet door was a safety hazard and removed it from the room. However, it was noted that the necessary repairs for the resident's room had not been documented in the TELS system, which is used to track maintenance needs. The Director of Nursing acknowledged that the broken door should not have been in the resident's room due to safety concerns. The facility's Resident Room Maintenance policy outlines the need for regular inspections and maintenance of resident rooms to ensure safety, but these procedures were not followed in this instance.
Failure in Weight Monitoring for High-Risk Resident
Penalty
Summary
The facility failed to ensure proper weight monitoring for a resident at nutrition risk, identified as R20, who was observed in bed with severe cognitive impairment and dependent on a feeding tube. The resident's electronic health record indicated a history of fecal impaction, cerebral palsy, acute and chronic respiratory failure, and anoxic brain damage. Despite being classified as comatose and totally dependent on staff for all activities of daily living, R20 did not have an accurate readmission weight recorded, nor were weekly weights documented as required. The resident's recorded weights showed significant fluctuations, with a noted error in weight documentation by the registered dietitian. Interviews with the registered dietitian and the Director of Nursing confirmed that R20 was at high risk for weight loss and should have been reweighed weekly until the weight stabilized. The facility's policy on unintended weight loss required new residents to be weighed upon admission and weekly for four weeks, with re-weights initiated for specific variances. However, R20's weight was not accurately monitored, and the necessary re-weights were not conducted, leading to a potential compromise in the resident's nutritional status going undetected.
Deficiencies in Tracheostomy Care and Emergency Equipment Availability
Penalty
Summary
The facility failed to have emergency tracheostomy supplies readily available for a resident, identified as R175. During an observation, it was noted that R175, who had a tracheostomy tube, did not have an emergency trach bag or box visible in their room. Licensed Practical Nurses (LPNs) W and X were unable to locate the necessary emergency equipment, which was supposed to be tacked on a bulletin board that was found empty. The Director of Nursing (DON) confirmed that the emergency trach equipment should have been present in the room to replace the trach tube immediately if it became dislodged. Additionally, the facility did not consistently follow the physician's medical orders for tracheostomy care for another resident, identified as R74. R74, who had a tracheostomy tube, reported that trach care was provided only once a week, despite physician orders requiring daily changes of the inner cannula, trach tie, and collar every shift and as needed. A review of R74's treatment record revealed multiple instances where these changes were not documented as completed. The DON acknowledged that the nurses should have adhered to the physician's orders for trach care.
Expired Medical Supplies Found in Resident's Room
Penalty
Summary
The facility failed to ensure that medical supplies for a resident, identified as R10, were not expired. During an observation, it was noted that R10, who was in bed eating lunch, had expired tracheostomy care supplies in their room. Although R10 did not have a tracheostomy, they had a stoma, and the supplies were intended for stoma care. The Licensed Practical Nurse (LPN) initially stated that R10 did not have a tracheostomy but had a stoma. Upon further inspection by the Director of Nursing (DON) and the State Surveyor, it was found that the supplies included a box of heat and moisture exchangers (HME) and three full boxes of stoma caps, all of which were expired. R10's clinical record indicated a history of cancer of the larynx and supraglottis, and the presence of an artificial larynx, with intact cognition as per a Minimum Data Set assessment. The DON acknowledged that the expired supplies should not have been stored with unexpired supplies and should have been removed to prevent their use. During the exit conference, neither the Nursing Home Administrator nor the DON provided additional documentation or information regarding the expired supplies.
Failure to Maintain Resident Privacy Due to Broken Window Blinds
Penalty
Summary
The facility failed to maintain visual privacy for a resident by not repairing broken window blinds, which resulted in feelings of disrespect and the potential for exposure during care. The resident, who was observed in bed covered with a sheet and not wearing a gown, expressed dissatisfaction with the broken blinds that had been covered with a soiled sheet for some time. The resident was concerned about being visible from the outside, especially at night, and was frustrated that the staff had not addressed the issue. The blinds had several broken slats, preventing them from closing properly, which compromised the resident's privacy. The resident, who requires substantial to maximal assistance with activities of daily living, was admitted to the facility with multiple diagnoses, including cerebrovascular disease, epilepsy, hypertension, osteoporosis, and chronic kidney disease. Interviews with the Director of Maintenance and the Director of Nursing revealed that the nursing staff was responsible for notifying maintenance about repairs needed in residents' rooms. However, the facility's policy on resident room maintenance was not followed, as the broken blinds were not repaired, leading to the deficiency in maintaining the resident's privacy.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement proper hand hygiene and glove use during wound care for one resident and did not provide the proper receptacle for the disposal of PPE for another resident. Specifically, a wound nurse did not perform hand hygiene before applying gloves, did not change gloves or perform hand hygiene between removing an old dressing and applying a new one, and did not place wound supplies on a barrier. Additionally, the nurse exited the room without performing hand hygiene after removing gloves. The Director of Nursing confirmed that these actions were against the facility's standard precautions policy, which mandates hand hygiene and proper glove use to prevent cross-contamination. Another deficiency was observed in the room of a resident in isolation for Candida Auris. The room lacked an appropriate receptacle for the disposal of PPE, having only a small garbage can with a thin, clear plastic liner. The Director of Nursing acknowledged the need for an appropriate trash receptacle to ensure proper disposal of PPE. The facility's infection prevention and control policy requires measures to reduce the risk of acquiring and transmitting infections, which were not followed in this instance.
Failure to Prevent Use of Physical Restraints
Penalty
Summary
The facility failed to prevent the use of physical restraints on a resident, resulting in potential physical and psychosocial harm. The resident, who had diagnoses including diffuse traumatic brain injury, anoxic brain damage, and dementia, was found restrained in bed with garbage bags, a gown, and a sheet. The resident's medical records showed no orders, consents, assessments, or care plans for the use of restraints. The incident was reported by a nurse who discovered the resident tied up and immediately took steps to free the resident and notify the appropriate authorities. Interviews with staff revealed that the CNA responsible for restraining the resident claimed she did so to prevent the resident from choking on pieces of a brief. However, the facility's policy clearly states that physical restraints are not to be used for discipline or convenience and must be accompanied by proper documentation and consent. The Director of Nursing confirmed that the facility is a restraint-free building and acknowledged that the restraints used were not approved types.
Failure to Report Allegations of Abuse and Improper Use of Restraints
Penalty
Summary
The facility failed to report allegations of abuse for one resident, resulting in the allegations not being reported to the State Agency in a timely manner. The resident, who had severe cognitive impairments and required dependent assistance for mobility, was found restrained with a plastic bag, a gown, and a sheet. The CNA responsible for the restraint claimed it was to prevent the resident from choking on pieces of a brief. The incident was reported internally but not to the State Agency as required by the facility's policy. The Nursing Home Administrator did not consider the incident as abuse and therefore did not report it, despite the facility's policy mandating immediate reporting of such incidents. The resident's clinical chart revealed no orders, consents, assessments, or care plans for the use of restraints. Interviews with the LPN and DON confirmed that the facility is a restraint-free building and that the restraints used were not approved. The facility's policy clearly states that residents have the right to be free from abuse and restraints imposed for discipline or convenience. The failure to report the incident to the State Agency and the improper use of restraints led to the deficiency cited in the report.
Failure to Provide Proper Wheelchair Armrest Leads to Resident Fall
Penalty
Summary
The facility failed to provide an armrest on a resident's wheelchair, resulting in the resident falling from the wheelchair and sustaining a large hematoma. The resident, who had a history of falls and impaired cognition, was sent to dialysis with only one armrest on the wheelchair. During the dialysis appointment, the resident fell and had to be taken to the hospital for treatment of a head injury and hyperkalemia. The resident's care plan included the need for a safe environment and functioning wheelchair, but this was not adhered to during the incident. The CNA responsible for preparing the resident for transport admitted to not attaching the second armrest, believing it was safe without it. The DON confirmed that it was the facility's expectation that wheelchairs have both armrests intact during transport to prevent falls. However, there was no specific policy provided that outlined the need to ensure proper equipment assembly before transportation. The incident highlights a lapse in following the resident's care plan and ensuring the safety of the equipment used for transport.
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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