The Timbers Of Cass County
Inspection history, citations, penalties and survey trends for this long-term care facility in Dowagiac, Michigan.
- Location
- 55432 Colby St, Dowagiac, Michigan 49047
- CMS Provider Number
- 235652
- Inspections on file
- 34
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at The Timbers Of Cass County during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide required 30‑day written notice, appeal rights information, and adequate discharge planning for two residents whose discharges were initiated by the facility. One cognitively intact resident with diabetes, a Foley catheter, bowel incontinence, and malnutrition risk was pressured to leave due to an unpaid balance and discharged to a hotel without food resources, catheter‑care training, or a glucometer, despite APS having deemed his home uninhabitable. Another resident with severe cognitive impairment, a colostomy, and reduced mobility was told he had to leave on short notice, and his DPOA reported being warned he would be put outside if not picked up; he was discharged home alone without documented colostomy‑care training or a home safety evaluation for his walker. The NHA confirmed that no written discharge notices or appeal documents were provided and that required involuntary transfer/discharge forms were not submitted, contrary to facility policy requiring written notice at least 30 days before a facility‑initiated discharge.
The facility failed to employ a qualified Activity Director, as required by federal and state regulations, and did not ensure that activity assessments were conducted or that individualized activity information was shared with staff. As a result, a resident with a history of stroke and depression, who was cognitively intact, reported a significant decline in available activities, increased boredom, and loss of meaningful engagement, with similar concerns observed among other residents.
The facility did not provide individualized activities for several residents, including those with cognitive and physical impairments, resulting in a lack of engagement and unmet preferences for music, socialization, and meaningful activities. Staff and family interviews, as well as direct observations, revealed that residents were left unengaged, with limited or no access to preferred activities, and that activity programming was not tailored or consistently offered, especially for those unable to participate in group events.
A resident who was cognitively intact was documented as attending several activities that she did not actually participate in. Staff interviews revealed that activity attendance was sometimes recorded at the end of the day, leading to discrepancies and inaccurate records of resident participation.
A resident with dementia who developed symptoms and tested positive for influenza was not placed under appropriate transmission-based precautions. Staff, including housekeeping and the Activities Director, entered the resident's room wearing only KN95 masks, did not use additional PPE, and failed to perform hand hygiene upon exit. Isolation signage and a PPE cart were not present, and the resident was invited to participate in group activities despite the confirmed infection.
The facility failed to manage food storage and cleanliness, with unlabeled and undated food items found in coolers and nourishment rooms, and inadequate cleaning of kitchen equipment. Dietary staff did not consistently follow labeling and cleaning protocols, leading to potential health risks for residents. Additional issues included improper storage of wet pans, a soiled stock pot, and the use of a stained bowl for serving food.
The facility failed to honor the mealtime preferences of residents, including one with vascular dementia and major depressive disorder, by not allowing them to eat in the communal dining room due to staffing concerns. Despite being fully staffed, the facility maintained dining restrictions, leading to resident frustration and discontent, contradicting their policy on self-determination.
A resident was not informed in a timely manner about the exhaustion of their Medicare Part A benefits, leading to unexpected financial liability. The resident, who was cognitively intact, was distressed upon learning of a $10,000 bill. The facility's admissions and billing teams failed to communicate the resident's limited coverage, resulting in a missed notification.
The facility failed to develop comprehensive care plans for two residents, one with a nephrostomy bag and another with diabetes and medication needs. The responsible MDS RN confirmed these oversights, leading to potential unmet needs.
A resident experienced dysuria for seven days due to a delay in obtaining a urinalysis (UA) at the facility. The resident reported symptoms to an RN, who documented the complaint, and an NP gave a verbal order for a UA, which was not placed until several days later. The NP confirmed the delay in care, acknowledging that the UA should have been completed the same day the resident reported pain.
A resident with vascular dementia and severe cognitive impairments did not receive individualized activities based on their preferences and needs. Observations showed the resident often sat alone in the day room without engagement in preferred activities like music or pet interactions. Staff interviews revealed limited room visits and a lack of sensory stimulation activities, highlighting a gap in implementing individualized activity plans.
A resident with severe cognitive impairment and difficulty swallowing experienced significant weight loss due to the facility's failure to ensure timely and consistent weight monitoring. Despite being on a Mechanical Soft diet, the resident's weight dropped significantly, and the necessary reweights were not obtained. The RD and DS did not follow up on the weight changes, and the DON was not informed in a timely manner, leading to a decline in the resident's nutritional status.
A facility failed to document education provided to a resident or their representative about the benefits and risks of prescribed psychotropic medications. The resident, who was severely cognitively impaired, had consent for an antipsychotic but lacked documentation for antidepressants. The Social Services Director was unsure if education on antidepressants was documented, and no evidence was provided before the survey exit.
The facility failed to honor the food preferences of two residents, leading to complaints and potential nutritional decline. A resident with diabetes and anxiety did not consistently receive her ordered meals, and another resident with severe cognitive impairment often lacked her preferred drink, chocolate milk, due to supply issues. These deficiencies were noted in Resident Council Minutes, indicating ongoing concerns.
A facility failed to maintain proper infection control standards for a resident's tube feeding equipment, resulting in potential pathogen harborage. The equipment, including the feeding pole and pump, had dried splatters of the feeding formula. An LPN confirmed the need for immediate cleaning to prevent infection but was unaware of who was responsible for this task, highlighting a lapse in infection control practices.
The facility failed to ensure that residents were screened for eligibility and received Pneumococcal vaccinations if eligible, affecting three residents. One resident had not been screened or offered an updated vaccine since their last vaccination in 2018, despite consent being given. Another resident had not received a vaccine according to records, and a third resident was due for an update since their last vaccination in 2015. The DON acknowledged the oversight in monitoring and administering vaccines, contrary to the facility's policy.
The facility failed to offer COVID-19 vaccinations to two residents, increasing the risk of infection. Both residents, admitted with weakness, had not been screened or offered vaccines since their last immunizations. The DON admitted to not screening or offering vaccines to eligible residents, contrary to the facility's policy.
The facility failed to maintain clean conditions for two residents, resulting in deficiencies. A resident with pulmonary hypertension and diabetes had a soiled privacy curtain and dusty blinds, while another with vascular dementia had a visibly soiled wheelchair. Observations confirmed these issues over multiple days, and interviews revealed that cleaning protocols were not followed.
A resident with a history of exit-seeking behavior eloped from the facility due to inadequate supervision and ineffective alarm systems. Despite being identified as an elopement risk, the resident's care plan lacked specific interventions, and the facility's alarm system was insufficient, as it could not be heard from the resident units. The resident was able to leave the premises unnoticed and was later found outside, highlighting significant gaps in the facility's elopement prevention measures.
A facility failed to report a resident-to-resident abuse incident involving two cognitively impaired residents in a timely manner. The incident, which resulted in a skin tear for one resident, was not reported to the State Agency within the required two-hour timeframe due to technical difficulties experienced by the NHA. Despite the facility's policy allowing multiple reporters, the NHA was solely responsible for the submission, leading to the delay.
A resident with visual impairments was transported in a wheelchair without footrests by staff, despite the requirement for footrests when being pushed. Staff acknowledged the need for footrests but continued to transport the resident without them, citing the resident's preference.
The facility failed to securely store medications in three treatment carts, leaving them accessible to anyone on the unit. Observations revealed that [NAME] Pain Gel and other topical treatments were left unsecured on carts behind nurse's stations. Interviews with LPNs confirmed that these medications require a physician's order and should be applied by licensed nurses. The DON acknowledged the oversight, and it was noted that the medication cart at the Evergreen nurse's station was unlocked.
The facility failed to ensure proper hand hygiene during medication administration for three residents, leading to potential infection risks. Observations showed that an LPN did not perform hand hygiene while administering medications, using Sani-Cloths instead of proper hand sanitizers. Another LPN also failed to sanitize hands after administering an insulin injection. Interviews confirmed that hand hygiene should be performed between residents and before and after glove use, as per facility policy.
Failure to Provide 30‑Day Notice and Safe Discharge Planning for Two Facility‑Initiated Discharges
Penalty
Summary
The deficiency involves the facility’s failure to provide required 30‑day written notice of facility‑initiated discharge, failure to inform residents of their right to appeal, and failure to implement appropriate discharge planning and preparation for two residents. For the first resident, an older male with traumatic ischemia of muscle, diabetes mellitus, neuromuscular bladder dysfunction with an indwelling Foley catheter, bowel incontinence, malnutrition risk, and fluctuating ADL abilities, the MDS showed he was cognitively intact. His care plan included management of his Foley catheter, diabetes, incontinence, and a planned discharge with needed equipment and supplies. Despite this, he reported being told by the NHA that he had to leave because he had met all his goals, and he was discharged to a hotel one day after that meeting without being informed of his right to appeal the discharge and without a glucometer for blood sugar monitoring. Staff interviews indicated that the first resident sometimes needed help with bowel incontinence and catheter management, and that he expressed concern about having no food when leaving, wishing he had oatmeal and milk to take with him. The former social services staff reported that the resident’s home had been deemed unsafe and uninhabitable by APS, that the resident was hesitant to leave because he knew repairs would take months, and that the facility pushed for discharge due to his outstanding balance and failure to pay. The APS caseworker described the home as having severe clutter, tripping hazards, no running water, utility issues, and a kicked‑in front door, and stated the resident confirmed he could not return there until it was cleaned and repaired. The resident’s DPOA reported being told by the NHA that the resident could not afford to stay, was not informed of any option to remain or appeal, and later learned he had been discharged without her knowledge and without a glucometer. An emergency department note documented that the resident reported being moved from a SNF to a motel, felt unable to care for himself, had no way to check his glucose at home until prescribed a glucometer there, and that EMS had been called by home health because he was covered in feces. For the second resident, an older male with malignant neoplasm of the colon, alcohol dependence with delirium, and intestinal perforation, the MDS showed severe cognitive impairment (BIMS 5), a colostomy, and independence only for wiping the ostomy opening. His care plan identified impaired cognition with a goal of making safe decisions with staff supervision. Social services documentation showed he was notified one day prior that he would discharge home the next day. His DPOA reported telling the NHA there was no safe place for him to go and no one to care for him, and that the NHA focused on not wanting him to build up medical debt. She stated she ultimately picked him up because an unknown staff member told her that if he was not picked up by midnight, he would be escorted outside and the door locked behind him. She reported that he initially did not want to discharge but agreed after repeated staff inquiries about when his ride was coming, that he had never previously cared for his colostomy, had poor short‑term memory and reduced mobility, and that his walker did not fit through his bathroom door and he had fallen several times at home. Therapy and nursing leadership interviews confirmed that the second resident should have received colostomy care training and that no documentation of such training existed. The COTA stated that a home evaluation to determine safe use of the walker in the home was not completed and that, due to his cognition, he would have needed repetitive training and displayed impulsivity with unfamiliar tasks. The DON reported the facility could not provide documentation of colostomy training for this resident or catheter and blood glucose training and provision of a glucometer for the first resident. The NHA acknowledged that the DPOA for the second resident did not want him discharged on the identified date but ultimately took him home, asserted that all discharges were voluntary, and confirmed that the facility did not provide either resident with written notice of discharge or information on the right to appeal. The governing body confirmed that the required state involuntary transfer/discharge and appeal forms were not submitted for either resident, and the facility’s own policy required written notice in a language the resident or representative could understand, given at least 30 days before a proposed facility‑initiated discharge.
Unqualified Activity Director and Lack of Individualized Activities
Penalty
Summary
The facility failed to employ an Activity Director who met the required federal and state qualifications for the position. The Activities Director, who assumed the role approximately nine months prior, did not possess certification as an Activity Director, nor could the facility provide verification that she had two years of full-time experience in a therapeutic activities program as required. The Nursing Home Administrator confirmed that the Activities Director was hired with the expectation to obtain certification but was not held accountable for achieving this requirement. Interviews and record reviews revealed that the Activities Director was not conducting activity assessments as required, and was unaware of the facility's initial or annual activity assessment forms. Instead, she relied solely on section "F" of the Minimum Data Set (MDS) to gather information about residents' leisure preferences and needs. The Activity Assistant reported not receiving any information about individual resident preferences or needs, making it difficult to provide individualized activities. The Activities Director also acknowledged that some residents were dependent on structured leisure activities and that isolation could occur if activities were not provided based on each resident's needs and preferences. A resident with a history of stroke, major depressive disorder, and hemiplegia, who was cognitively intact, reported a significant decline in the number and variety of activities over the past nine months, especially on weekends and evenings. The resident expressed feelings of boredom and frustration due to the lack of activities and the discontinuation of her volunteer role in the activity store, which had become nearly empty. The resident also observed that more residents were unengaged and sitting in their rooms, and several had expressed similar feelings of boredom.
Failure to Provide Individualized Activities Based on Resident Preferences
Penalty
Summary
The facility failed to provide individualized activities based on the preferences, needs, and abilities of four residents, as required by regulation. Multiple observations and interviews revealed that residents with varying degrees of cognitive and physical impairment were left without meaningful engagement or access to activities tailored to their interests. For example, one resident with legal blindness and moderate cognitive impairment was unable to use his smart device to listen to music, despite this being a documented preference, and reported feeling bored and anxious in his room. Another resident with severe cognitive impairment and a history of depression was observed sitting passively in a lounge with no staff engagement, and her family member reported that the only activity provided was popcorn, with no regular access to music or religious services as preferred. A third resident, moderately cognitively impaired, was observed repeatedly in her room without music or television, despite her care plan indicating these as important interests. Her family member reported that the facility had not contacted her about the resident's leisure interests and noted a lack of mental stimulation, with the resident appearing increasingly disconnected. The fourth resident, who was cognitively intact and previously active as a volunteer, reported a significant decline in available activities, especially on weekends and evenings, and expressed frustration over the lack of purpose and engagement due to the reduction in activity programming and the near-empty resident store. Staff interviews corroborated these findings, with activity assistants and CNAs reporting a lack of structured one-on-one visits, insufficient information about resident preferences, and a reduction in group and individualized activities, particularly for those with cognitive impairments. The Activities Director acknowledged that assessments were not being completed as required and that evening programming was not provided according to facility policy. The Nursing Home Administrator confirmed these deficiencies, noting that the current activity program did not meet policy standards and that individualized activities were not being offered.
Inaccurate Documentation of Resident Activity Participation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who was reviewed for activity participation documentation. The resident, who was cognitively intact as evidenced by a perfect score on the Brief Interview for Mental Status (BIMS), reported that she did not attend several activities that were documented in her records, including a movie, a social hour, and a resident council meeting. The resident was able to recall with certainty that she did not participate in these events, and her recollection was supported by a Certified Nursing Assistant who confirmed the resident's cognitive abilities and reliability in recalling daily events. Interviews with the Activities Director and Activity Assistants revealed inconsistencies in the documentation process. The Activities Director stated that daily records of resident participation were maintained and reviewed, while one Activity Assistant admitted to noticing discrepancies in the records. Another Activity Assistant reported that she often waited until the end of the day to document attendance, which sometimes made it difficult to accurately remember which residents attended each activity. These practices led to inaccurate documentation of the resident's participation in activities, resulting in incomplete and unreliable medical records.
Failure to Implement Transmission-Based Precautions for Resident with Influenza
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions for a resident who was symptomatic and later confirmed to have influenza. The resident, who had a diagnosis of unspecified dementia and was alert and oriented, reported a severe sore throat and cough, with wheezing noted on auscultation. The physician assistant was notified, and testing for Influenza A and B was ordered. Despite these symptoms and the subsequent positive flu test, no isolation signage was present on or near the resident's room, and isolation precautions were not visibly in place at the time of observation. During the period when the resident was symptomatic and should have been under droplet precautions, two housekeeping staff entered the room to clean the carpet. They wore KN95 masks but did not use any other personal protective equipment (PPE) and failed to perform hand hygiene upon leaving the room. The staff also continued to wear the same masks as they moved through the hallway, potentially increasing the risk of cross-contamination. Additionally, the Activities Director entered the resident's room wearing only a KN95 mask, did not use additional PPE, and invited the resident to a group activity, further disregarding isolation protocols. The Activities Director also did not perform hand hygiene upon leaving the room and continued to wear the same mask in the hallway. Interviews with staff confirmed that the resident had tested positive for influenza and that requests for isolation signage and a PPE cart had been made but were not yet in place. The Director of Nursing/Infection Preventionist stated that isolation precautions should be implemented at the onset of symptoms for suspected contagious illnesses. Facility policy and CDC guidelines both require droplet precautions for influenza, including the use of appropriate PPE, hand hygiene, and isolation signage, none of which were properly implemented for this resident.
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to properly manage food storage and cleanliness, leading to potential health risks for residents. During an initial kitchen and food service tour, several issues were observed, including opened food containers in the walk-in cooler and reach-in cooler that were not labeled with opened or discard dates. Additionally, the plate warmer used for resident meal trays contained plates with dried food debris, indicating inadequate cleaning practices. In the nourishment rooms, various food items were found unlabeled, undated, and in some cases, spoiled or moldy, further highlighting the lack of proper food management. The facility's dietary staff were responsible for cleaning the nourishment room refrigerators and freezers, but the cleaning schedule was not effectively maintained. The Dietary Supervisor reported that staff attempted to clean when they noticed dirt, with a deep scrub scheduled once a week. However, the expectation for food labeling and dating was not consistently met, as evidenced by numerous unlabeled and undated food items. The failure to discard opened drinks after five days and prepared foods after three days from preparation was also noted, increasing the risk of foodborne illness. During a follow-up tour, additional deficiencies were identified, such as wet pans being improperly stored, a stock pot with dried residue, and a knife storage rack with dust and debris. Furthermore, a stained bowl was used to serve gravy to a resident, despite the availability of new bowls. These observations indicate a systemic issue with maintaining cleanliness and proper food handling procedures, which could compromise the safety and well-being of residents consuming food from the facility.
Failure to Honor Resident Mealtime Preferences
Penalty
Summary
The facility failed to honor the mealtime preferences of several residents, including a resident with vascular dementia and major depressive disorder, who expressed a desire to eat in the communal dining room. Despite the resident's care plan indicating the importance of socialization and the dining room setting for initiating self-feeding, the facility did not accommodate this preference due to staffing concerns. The resident's family member, who visited daily to provide socialization and support, reported that the facility had been informed of the resident's preference but did not make the necessary arrangements. Interviews with staff and residents revealed that the facility had not allowed residents to eat their evening or weekend meals in the dining room for nearly two years, citing staffing issues as the reason. The Director of Nursing acknowledged the importance of communal dining for residents' socialization and independence but noted that the dining restrictions remained despite the facility being fully staffed. The facility's policy on self-determination emphasized respecting residents' autonomy, yet the dining restrictions contradicted this policy, leading to resident frustration and discontent.
Failure to Notify Resident of Medicare Part A Exhaustion
Penalty
Summary
The facility failed to provide timely notification to a resident regarding the exhaustion of Medicare Part A benefits, resulting in the resident being unaware of changes in financial liability. The resident, who was cognitively intact, was informed late about the lack of Medicare coverage and the impending financial burden of approximately $10,000. The resident expressed distress and uncertainty about how to manage the unexpected financial responsibility. The deficiency occurred due to a lack of communication and oversight within the facility's admissions and billing processes. The Business Office Manager and Admission Director were unaware of the resident's limited Medicare coverage at the time of admission, and the MDS RN, responsible for notifying residents of benefit exhaustion, was not informed in time. This oversight led to the resident not receiving the required notice three days before the benefits ended, as per protocol.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, resulting in the potential for unmet medical, physical, mental, and psychosocial needs. Resident #53 was admitted with a need for assistance with personal care and had an order to empty a left nephrostomy bag every shift. However, a review of the care plan revealed that there was no care plan developed for the nephrostomy bag. During an interview, MDS RN M, who was responsible for ensuring care plan orders were in place, confirmed that this was an oversight. Similarly, Resident #90 was admitted with a diagnosis of type 2 diabetes mellitus and had orders for medications including Duloxetine, Eliquis, and Olanzapine. The care plan review showed that there was no care plan developed for the resident's diabetes diagnosis or the use of anticoagulant and psychotropic medications. MDS RN M acknowledged that a care plan should have been in place for these conditions and medications, but it was missed.
Delay in Urinalysis Order Leads to Prolonged Resident Discomfort
Penalty
Summary
The facility failed to provide care in accordance with professional standards for a resident who experienced dysuria for approximately seven days. The resident, who required assistance with personal care, initially reported frequent urination and suspected a urinary tract infection (UTI) to a registered nurse (RN) on 10/24/24. The RN documented the complaint in the provider notification book. The following day, a nurse practitioner (NP) saw the resident and noted an increase in urinary frequency and burning, indicating consent for work for a UTI. However, the urinalysis (UA) was not ordered until 10/29/24, despite the resident's ongoing complaints of pain with urination. Interviews revealed that the NP had given a verbal order for a UA to a licensed practical nurse (LPN) on 10/24/24, but the order was not placed. The NP followed up on 10/25/24 and discovered the UA had not been ordered, prompting another request to staff. The delay in obtaining the UA resulted in the resident experiencing prolonged discomfort. The NP confirmed that the UA should have been completed the same day the resident reported pain, acknowledging the delay in care due to the facility's failure to promptly place the order.
Failure to Provide Individualized Activities for Resident with Dementia
Penalty
Summary
The facility failed to provide individualized activities based on resident preferences, needs, and abilities for Resident #55, who was reviewed for activities. Resident #55 was admitted with diagnoses including vascular dementia and cognitive communication deficit. The Minimum Data Set (MDS) assessment indicated that Resident #55 had severe cognitive impairments, including short- and long-term memory deficits, disorganized thoughts, and was rarely understood. Despite these challenges, the resident's care plan noted preferences for activities such as listening to music, being around pets, and spending time in groups. Observations revealed that Resident #55 was often left alone in the day room without engagement in preferred activities. The resident was seen sitting in a wheelchair, flexed at the hips, with eyes cast downward, and not interacting with the environment or other residents. The television was on, but Resident #55 did not appear aware of it, and no music was available. Interviews with staff indicated that room visits were limited to brief interactions, and there was a lack of sensory stimulation activities provided to Resident #55 over a five-month period. The Activities Director reported that residents who did not attend group activities should receive room visits 2-3 times a week, and sensory stimulation activities were supposed to be provided regularly. However, the Activity Assistant and a Certified Nursing Assistant noted limitations in the activities offered, particularly for residents with severe cognitive deficits. The facility had some activity supplies available, but there was uncertainty among staff about which residents used them, indicating a gap in the implementation of individualized activity plans for residents like Resident #55.
Failure in Timely Weight Monitoring Leads to Undetected Weight Loss
Penalty
Summary
The facility failed to ensure timely and consistent weight monitoring for a resident, leading to undetected weight loss and a decline in nutritional status. The resident, who had severe cognitive impairment and difficulty swallowing, was observed to have significant weight loss over a short period. Despite being on a Mechanical Soft diet and receiving nutritional supplements, the resident's weight dropped from 144.6 lbs to 126.0 lbs within a few weeks, indicating a 12.8% weight loss. The facility's dietary and nursing staff did not adequately monitor the resident's weight changes. The Registered Dietitian (RD) and Dietary Supervisor (DS) failed to follow up on the significant weight loss recorded on 9/13/2024. Although the resident was placed on a weekly weight monitoring list, the necessary reweights were not obtained, and the staff did not communicate effectively about the resident's nutritional needs. The RD was only present at the facility once a month and did not attend weekly Standards of Care (SOC) meetings, where such issues should have been discussed. The Director of Nursing (DON) and other staff members were not informed of the resident's weight loss in a timely manner. The DON was unaware of the weight loss until the day before the survey, and the weight monitoring policy was not followed. The policy required reweights to be conducted within 48 hours of a significant weight change, but this was not done. The lack of communication and follow-up among the interdisciplinary team contributed to the deficiency in addressing the resident's nutritional needs.
Lack of Documentation for Psychotropic Medication Education
Penalty
Summary
The facility failed to provide documentation of education to a resident or their representative regarding the intended or actual benefits versus potential risks or adverse consequences associated with psychotropic medications. This deficiency was identified for a resident who was prescribed multiple psychotropic medications, including mirtazapine, Zoloft, and Seroquel. The resident, who was severely cognitively impaired with a BIMS score of 6, had a signed consent form for the antipsychotic medication Seroquel but lacked documentation of education for the antidepressants mirtazapine and Zoloft. During an interview, the Social Services Director (SSD) indicated that they were trained to obtain consent only for antipsychotic medications and were unsure if education on antidepressants was documented. Despite reviewing the resident's medical record, the SSD could not locate any documentation of education on the risks versus benefits of the antidepressant medications. The surveyor encouraged the SSD to provide additional documentation before the survey exit, but no such documentation was provided.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to consistently honor the food preferences of two residents, leading to complaints and potential negative impacts on their meal enjoyment and nutritional intake. Resident #27, who is cognitively intact and has a history of anxiety, depression, and diabetes, reported not consistently receiving the meals she ordered. This issue was corroborated by a Certified Nurse Aide who observed that Resident #27 and other residents did not receive the items they requested on their meal trays. During a meal trayline observation, a Dietary Assistant was seen placing a tray into the delivery cart without the requested pudding due to a shortage, which was later rectified by the Dietary Supervisor. Resident #78, who is severely cognitively impaired and requires assistance with eating, also experienced issues with meal preferences. Her family member reported that Resident #78 did not consistently receive her preferred drink, chocolate milk, due to delivery issues. This was significant as it was sometimes the only nourishment she would accept. A Certified Nursing Assistant confirmed that Resident #78's tray often lacked chocolate milk, and the kitchen staff frequently cited supply issues. These deficiencies were noted in the Resident Council Minutes, highlighting ongoing concerns about incorrect food and unmet dietary preferences.
Infection Control Deficiency in Tube Feeding Equipment
Penalty
Summary
The facility failed to adhere to professional standards of infection control concerning a resident's tube feeding equipment, leading to a potential risk of pathogen harborage and cross-contamination. The facility's policy on cleaning and disinfecting resident-care items, reviewed in January 2024, mandates that equipment be cleaned according to CDC recommendations and OSHA standards. Additionally, the policy on tube feeding specifies that the nursing department is responsible for all feeding equipment. However, during an observation, it was noted that the tube feeding equipment for a resident, who required total assistance with activities of daily living and had a diagnosis of stroke, was not properly maintained. The equipment, including the tube feeding pole, base, pump, and surrounding items, had splatters of a dried substance resembling the tube feeding formula. During an interview and observation with an LPN, it was confirmed that the splatters should have been cleaned immediately to prevent infection control issues, as they become sticky and attract dirt. The LPN was unaware of who was responsible for cleaning the equipment, indicating a lapse in the facility's infection control practices. This oversight in maintaining cleanliness of the tube feeding equipment presents a potential risk for infection in a vulnerable population.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were screened for eligibility and received Pneumococcal vaccinations if eligible, affecting three out of five residents reviewed. Resident #18 was admitted with a diagnosis of weakness and had last received a Pneumococcal vaccine in 2018. Despite the legal guardian's consent for vaccination dated 10/2/23, there was no verification that Resident #18 had been screened for eligibility or offered an updated vaccine since admission. The Director of Nursing (DON) confirmed that Resident #18 was due for an updated vaccine. Resident #35, admitted with difficulty walking, had not received a Pneumococcal vaccine according to the Michigan Care Improvement Registry. Although consent was given on 8/24/23, there was no verification of screening or offering of the vaccine. Similarly, Resident #48, admitted with weakness, had last received a Pneumococcal vaccine in 2015 and was due for an update. The DON acknowledged the oversight in monitoring and administering vaccines. The facility's policy required assessment and offering of vaccines upon admission, but this was not adhered to, leading to the deficiency.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to ensure COVID-19 immunizations were offered to two residents, resulting in a higher likelihood of infection and complications from COVID-19. Resident #18 was admitted with a diagnosis of weakness and had not been screened or offered a COVID-19 vaccine since their last immunization on 10/25/22. The Director of Nursing (DON) admitted that the facility was not screening and offering COVID-19 immunizations to eligible residents at admission or annually, and was unable to provide verification that Resident #18 had been offered the vaccine since admission. Similarly, Resident #48, also admitted with a diagnosis of weakness, had not been screened or offered a COVID-19 vaccine since their last immunization on 9/20/2022. The DON confirmed that this was missed as well. The facility's COVID-19 Vaccine Program Policy, last revised in 9/2024, mandates that COVID-19 vaccinations be offered to residents when supplies are available, in accordance with CDC and FDA guidelines, unless medically contraindicated or refused. However, the facility did not adhere to this policy, as evidenced by the lack of screening and offering of vaccines to these residents.
Deficiencies in Sanitary Conditions for Residents
Penalty
Summary
The facility failed to maintain clean and sanitary conditions for two residents, resulting in deficiencies in their living environment. Resident #27, who is cognitively intact and has diagnoses including secondary pulmonary arterial hypertension and type 2 diabetes mellitus, was found in a room with a stained and soiled privacy curtain and dusty blinds. Despite the resident's report that these items were never cleaned, observations confirmed the lack of cleanliness over a 24-hour period. Interviews with housekeeping staff revealed that the privacy curtains should be disinfected daily and replaced if dirty, and blinds should be dusted as needed, but these procedures were not followed. Resident #55, who has vascular dementia and a cognitive communication deficit, was observed in a visibly soiled wheelchair with dried brown and white liquids and food crumbs on various parts of the chair. Despite the resident's inability to express preferences, the condition of the wheelchair was noted to be uncomfortable for a reasonable person. Observations over two days confirmed the lack of cleaning, indicating a failure in maintaining sanitary conditions for the resident's equipment.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Alarm Systems
Penalty
Summary
The facility failed to prevent the elopement of a resident, identified as R82, who was at risk for elopement due to cognitive impairment and a history of exit-seeking behavior. Despite being identified as an elopement risk, the resident's care plan did not include specific interventions to prevent elopement until after the incident occurred. The resident was able to leave the facility unnoticed and was later found outside, highlighting a lack of adequate supervision and ineffective alarm systems. R82 had a history of wandering and exit-seeking behavior, as documented in progress notes and elopement risk assessments. The resident was moderately cognitively impaired and required substantial assistance with daily activities. Despite these risk factors, the facility did not implement sufficient monitoring or interventions to prevent the resident from leaving the premises. The resident's care plan lacked specific elopement precautions, and there were no orders for increased supervision or frequent checks prior to the incident. The facility's alarm system was inadequate, as the front door alarm could not be heard from the resident units, and the French doors separating the lobby from the resident areas were closed after hours, further limiting staff's ability to respond to alarms. Staff interviews revealed that the resident had been exit-seeking throughout the night and was able to leave the facility while staff were occupied with other duties. The incident exposed significant gaps in the facility's elopement prevention measures, including insufficient staff presence and ineffective alarm systems.
Delayed Reporting of Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report a resident-to-resident abuse incident in a timely and accurate manner to the State Agency, involving two residents with severe cognitive impairments. Resident #104, diagnosed with Alzheimer's disease and vascular dementia with behavioral disturbances, and Resident #105, diagnosed with unspecified dementia and anxiety, were involved in an altercation at the nurse's station. The incident resulted in Resident #105 sustaining a skin tear on the left hand. The facility's policy requires that all alleged violations involving abuse be reported immediately, but not later than two hours after the allegation is made. The Nursing Home Administrator (NHA) was responsible for reporting the incident but failed to do so within the required timeframe. The incident occurred at 6:50 PM on 2/28/24, but the report was not submitted to the State Agency until 8:57 AM the following day. The NHA cited technical difficulties with a new laptop as the reason for the delay. Despite the facility's policy allowing for multiple reporters, the NHA was the sole individual responsible for the submission, which contributed to the delay in reporting the incident.
Failure to Ensure Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure the safe transport of a resident in a wheelchair by not using footrests, which is a necessary safety measure. The resident involved, identified as Resident #106, has significant visual impairments, including legal blindness, and is moderately cognitively impaired. Observations on multiple occasions revealed that the resident was being pushed in a wheelchair without footrests by staff members, including an Activities Aide and the Activities Director. Despite acknowledging the need for footrests, the staff continued to transport the resident without them, citing the resident's preference as a reason. Interviews with various staff members, including a Certified Nurse Assistant and a Registered Nurse, confirmed that footrests are required for residents being pushed in wheelchairs, especially for those who cannot self-propel due to visual impairments. The care plan for the resident indicated the use of a wheelchair for mobility and assistance with transfers, but there was no mention of footrests. The Director of Nursing was in the process of re-educating staff on the use of footrests, but this was not part of the deficiency findings.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications securely in three treatment carts, as observed during a survey. Medications, including a pain gel labeled as [NAME] Pain Gel, were found on top of treatment carts behind various nurse's stations, including Birch, Dogwood, and Evergreen. These carts were accessible to anyone on the unit, as there were no barriers to prevent access, and the medications were not locked as required by the facility's policy. Interviews with staff, including LPN Q and LPN P, confirmed that the [NAME] Pain Gel is a medication that requires a physician's order and should only be applied by licensed nurses. Despite this, the pain gel and other topical treatment creams and ointments with resident-specific information were left unsecured on the treatment carts, contrary to the facility's policy that mandates all medications be stored in locked compartments. The Director of Nursing (DON) B acknowledged during an interview and observation that all medications should be locked in the carts. Upon inspection, it was found that the medication cart at the Evergreen nurse's station was unlocked, and the medications were not secured inside the cart. This oversight was confirmed by LPN P, who was present at the time and began removing the medication items from the top of the treatment cart to secure them.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration for three residents, leading to potential risks of infection and cross-contamination. Observations revealed that an LPN did not perform hand hygiene while administering medications to two residents. The LPN was seen preparing and administering oral and injectable medications without washing hands or using hand sanitizer between tasks and residents. The LPN incorrectly used Sani-Cloths, intended for disinfecting surfaces, as a substitute for hand hygiene, which is against the facility's policy. Another LPN also failed to perform hand hygiene while administering medications to a third resident. This LPN did not sanitize hands after administering an insulin injection and before handling oral medications. Interviews with the LPNs and the Assistant Director of Nursing confirmed that hand hygiene should be performed between residents and before and after glove use. The facility's policy mandates hand washing after contamination with blood, after resident care, and before and after nursing procedures, which was not adhered to in these instances.
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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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