The Willows At East Lansing
Inspection history, citations, penalties and survey trends for this long-term care facility in East Lansing, Michigan.
- Location
- 3500 Coolidge Road, East Lansing, Michigan 48823
- CMS Provider Number
- 235700
- Inspections on file
- 24
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at The Willows At East Lansing during CMS and state inspections, most recent first.
A resident with multiple sclerosis, paraplegia, MASD, an indwelling catheter, and frequent bowel incontinence had a right thigh wound with a physician order for daily wound care between 2:00 PM and 10:00 PM. During incontinence care, surveyors observed that the wound dressing was dated several days earlier, despite the TAR showing that an LPN had documented the treatment as completed on two intervening days and refused on another day. The medical record contained no documentation of wound care refusals on the dates in question, and leadership acknowledged the discrepancy, indicating the LPN may have marked the treatment as done or failed to document refusals. This demonstrated that ordered daily wound care was not consistently provided or accurately documented according to the resident’s treatment orders.
A resident with multiple sclerosis, paraplegia, bowel incontinence, and MASD to the right thigh had a physician’s order for daily wound care, yet surveyors observed a thigh dressing dated several days earlier, indicating it had not been changed as ordered. The TAR showed wound care documented as completed on multiple days and refused on one day, but the observed unchanged dressing and the absence of documented refusals on certain days conflicted with these entries. The DON acknowledged that refusals should be charted and that an LPN may have incorrectly recorded wound care as completed or failed to document refusals, resulting in an inaccurate medical record for the resident’s wound treatment.
A resident with dementia and anxiety exhibited increasing aggressive behaviors, particularly during sundowning episodes, without a comprehensive care plan in place. Despite documentation of these behaviors, the facility failed to develop interventions to guide staff. Social workers were not promptly informed of incidents, delaying care plan development for the resident's needs.
A resident with severe cognitive impairment and a history of falls had an incomplete care plan that failed to specify the placement of a floor mat, despite multiple falls from the bed. Interviews with the DON and a CNA highlighted the lack of individualized instructions, leading to uncertainty in implementing fall prevention measures.
A resident with severe cognitive impairment was not provided with a meaningful and engaging activity program. Despite having preferences for activities like pet visits and music, the resident was often observed sitting in front of a television playing MTV, which they did not engage with. The facility did not offer pet therapy and failed to document any invitations or encouragement for the resident to participate in other available activities.
A resident with dementia and anxiety exhibited increasing aggressive behaviors, including conflicts with roommates and attempts to leave the facility. Despite being on medication, there were no documented interventions to manage these behaviors, and staff were unsure of how to assist. The facility's documentation and communication were inadequate, delaying necessary follow-up by social workers.
A resident with severe cognitive impairment and a history of gradual dose reductions for Risperidone had their medication increased to twice daily after a hospital stay, without documented justification. Facility staff, including social workers and the DON, could not provide a rationale for the change, and behavior reports did not indicate significant disturbances. The resident's daughter reported increased hallucinations, but no new orders were made.
The facility failed to offer an updated COVID-19 immunization to two residents who had previously contracted COVID-19. Both residents, with cognitive impairments and guardians, received their last COVID-19 vaccine in 2022. Despite being eligible for a booster 90 days post-infection in 2023, there was no documentation that they were offered the vaccine, resulting in a deficiency.
The facility failed to provide written transfer notices for two residents during hospital transfers. One resident, cognitively intact, was transferred three times without notice, while another with moderate cognitive impairment was transferred without notice during a hospitalization for urosepsis. Staff interviews confirmed the absence of required documentation.
The facility failed to provide two residents with written notice of the bed hold policy during hospital transfers. One resident, who was cognitively intact, was transferred multiple times without receiving the notice, as confirmed by staff interviews. Another resident with moderate cognitive impairment also did not receive the notice during a hospitalization, with staff indicating process changes may have contributed to the oversight.
A resident with a history of multiple medical conditions spilled mild temperature beverages on her lap, resulting in burns that were not properly assessed or treated by the facility. Initial assessments noted mild redness, but later observations revealed open areas on the thighs. Despite reports of blisters and redness by staff, no treatment orders or documentation were found in the resident's medical records.
A resident with a history of falls was left unattended in the shower by a CNA, resulting in a fall and injury. The resident, who did not request privacy, fell while reaching for a washcloth, leading to a hospital visit for stitches. The CNA assumed privacy was desired, despite knowing the resident's fall risk, and was later re-educated on proper supervision protocols.
Failure to Provide and Accurately Document Ordered Daily Wound Care
Penalty
Summary
Surveyors identified that ordered wound care was not completed as prescribed for a resident with multiple sclerosis, paraplegia, an indwelling urinary catheter, frequent bowel incontinence, and moisture associated skin damage (MASD). The resident’s MDS showed moderate cognitive impairment. A physician’s order dated 3/15/26 directed that the right thigh wound be cleansed with normal saline or wound cleanser, patted dry, skin prep applied to the peri-wound, collagen applied to the wound bed, and a border dressing applied, with the treatment to be done daily between 2:00 PM and 10:00 PM. A wound note on 3/16/26 documented a pink right thigh wound measuring 1 cm by 3 cm. On 3/20/26 at 12:02 PM, during incontinence care for loose stool that had leaked from the brief and soiled the bedding, surveyors observed a dressing on the back of the resident’s thigh dated 3/16/26, indicating that the dressing had not been changed since that date. Review of the Treatment Administration Record (TAR) showed that the daily wound care was documented as completed on 3/17/26 and 3/19/26 by an LPN, and as refused on 3/18/26. The medical record contained no indication that the resident refused wound care on 3/16/26 or 3/19/26. The DON acknowledged that the TAR reflected wound care as completed on 3/17/26 and 3/19/26 and stated that the LPN might have clicked it off as completed or forgotten to document refusals, while attempts by both surveyors and facility leadership to contact the LPN for clarification were unsuccessful. The ADON, who served as the wound nurse, confirmed that the resident had MASD requiring daily wound care and later reported that the resident refused wound care when requested on 3/20/26. These observations and record reviews showed a failure to provide and accurately document the ordered daily wound care for the right thigh wound.
Inaccurate Wound Care Documentation for Thigh MASD
Penalty
Summary
The deficiency involves the facility’s failure to ensure the accuracy of a resident’s medical record regarding wound care. The resident, admitted with multiple sclerosis, paraplegia, an indwelling urinary catheter, frequent bowel incontinence, and moisture associated skin damage (MASD), had a physician’s order dated 3/15/26 for daily wound care to a right thigh wound between 2:00 PM and 10:00 PM. The wound note on 3/16/26 documented a pink right thigh wound measuring 1 cm by 3 cm. On 3/20/26 at 12:02 PM, during incontinence care following an episode of loose stool incontinence that required a complete linen change, surveyors observed a dressing on the back of the resident’s thigh dated 3/16/26, indicating that the dressing had not been changed since that date. A CNA confirmed the dressing date of 3/16/26. Review of the Treatment Administration Record (TAR) showed that the resident’s wound care was documented as completed on 3/17/26 and 3/19/26 by an LPN, and as refused on 3/18/26. The facility was unable to reach the LPN to clarify the documentation. The ADON, who served as the wound nurse, stated that the resident had MASD requiring daily wound care and later reported that the resident refused wound care when requested on 3/20/26. The DON stated that any wound care refusals should be documented in the Progress Notes or TAR and acknowledged that the TAR showed wound care as completed on 3/17/26 and 3/19/26, suggesting the LPN might have incorrectly documented completion or failed to document refusals. The resident’s medical record did not indicate that wound care was refused on 3/16/26 or 3/19/26, resulting in inaccurate medical record documentation related to wound treatment.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for a resident, resulting in the potential for unmet care needs. The resident, who was admitted with diagnoses including unspecified dementia and anxiety, exhibited moderate cognitive impairment. Despite being on an antidepressant, the resident displayed increasing aggressive behaviors, particularly during sundowning episodes. These behaviors were documented in progress notes, but no care plan was developed to address the resident's increased confusion and aggression at night. Observations and interviews revealed that the resident expressed frustration with personal property issues and had conflicts with roommates, leading to aggressive incidents. Staff noted the resident's sundowning behaviors were becoming more frequent and aggressive, yet there were no interventions listed to guide staff on managing these behaviors. The interdisciplinary team was aware of the behavior concerns but had not developed a care plan to address them. The social workers involved were not immediately informed of a significant incident involving the resident and a roommate, delaying the development of a care plan. The lack of timely communication and follow-up resulted in the absence of a care plan for the resident's behaviors, including increased nighttime delirium and depression. This oversight highlights the facility's failure to ensure comprehensive care planning for the resident's needs.
Failure to Update Care Plan for Fall Prevention
Penalty
Summary
The facility failed to update a care plan to include detailed person-centered needs for a resident with severe cognitive impairment and a history of falls. The resident was admitted to the facility and had multiple falls since admission, resulting in abrasions to the forehead and left knee. Observations noted that the resident had a floor mat in their room, but the care plan did not specify which side of the bed the mat should be placed on, despite the resident's history of falling from the bed. Interviews with the Director of Nursing and a Certified Nursing Assistant revealed that the care plan was not individualized to specify the placement of the floor mat, which is crucial for preventing falls. The CNA indicated that care is driven by the care plan, and without specific instructions, staff would have to guess or rely on verbal reports to determine the correct placement of the mat. This lack of specificity in the care plan contributed to the deficiency in providing adequate fall prevention measures for the resident.
Failure to Provide Engaging Activities for Resident
Penalty
Summary
The facility failed to provide a meaningful, diverse, and engaging activity program for a resident diagnosed with a neurocognitive disorder with Lewy body, who was admitted with severe cognitive impairment. The resident's activity assessment indicated preferences for pet visits, being read to, easy listening music, and family visits. However, the facility's activity care plan included activities such as pet therapy, which was not offered, and other activities like Catholic services, going outside, bingo, socials, and music, which were not documented as attended by the resident. Observations over several days showed the resident repeatedly placed in front of a television playing MTV, which the resident did not engage with. Despite the facility having books, music programs, and socials, there was no documentation of the resident being invited or encouraged to participate in these activities. The Nursing Home Administrator acknowledged the lack of pet therapy and did not provide an explanation for the resident's lack of participation in other activities, nor was there any record of the resident refusing invitations to group activities.
Failure to Provide Adequate Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident #5 (R5), who was admitted with diagnoses including unspecified dementia, anxiety, and dysthymic disorder. R5 exhibited moderate cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 12. Despite being on an antidepressant, Escitalopram, R5 displayed increasing aggressive behaviors and agitation, particularly during the evening, known as sundowning. These behaviors included attempting to leave the facility, conflicts with roommates, and difficulty being redirected by staff. Observations and interviews revealed that R5's aggressive behaviors were not effectively managed, as there were no documented interventions to guide staff in addressing these behaviors. Incidents included R5 becoming agitated with a roommate over a closed door, throwing a roommate's shoes in the trash, and needing a room change due to conflicts. Staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), noted the increase in frequency and intensity of R5's behaviors but were unsure of any specific interventions in place. The facility's documentation and communication processes were inadequate, as evidenced by the lack of progress notes or social work assessments regarding R5's recent incidents. Social Workers were not informed of a significant incident until days later, delaying necessary follow-up. The absence of a comprehensive care plan with individualized interventions for R5's behavioral issues contributed to the deficiency in providing appropriate behavioral health care and services.
Unjustified Increase in Antipsychotic Medication for a Resident
Penalty
Summary
The facility failed to justify the increase in antipsychotic medication for a resident, identified as Resident #18, who was admitted with diagnoses including anxiety, major depressive disorder, and vascular dementia with psychotic disturbance. The resident had a history of gradual dose reductions (GDR) for Risperidone, an antipsychotic medication, with the last reduction noted on 12/19/23. Despite this, the resident's medication was increased to twice daily following a hospital stay from 3/21/24 to 4/3/24, without documented rationale for the change. The facility's records indicated that the resident was receiving Risperidone once daily, but observations and interviews revealed that the medication was administered twice daily. The facility's social workers and the Director of Nursing were unable to provide documentation or rationale for the increased dosage of Risperidone. The behavior analysis report and progress notes did not indicate any significant behavioral disturbances or distressful hallucinations that would justify the increase. The resident's daughter expressed concerns about increased hallucinations, but no new orders were made following this report. The lack of documentation and justification for the medication increase was noted as a deficiency by the surveyors.
Failure to Offer COVID-19 Booster to Residents
Penalty
Summary
The facility failed to offer an updated COVID-19 immunization to two residents, identified as Resident #7 and Resident #18, who were reviewed during a survey. Resident #7 was admitted with diagnoses including diabetes, sleep apnea, and vascular dementia, and had a moderate cognitive impairment score on the Brief Interview for Mental Status (BIMS). Resident #18 was admitted with atrial fibrillation, heart failure, and dementia, and had a severe cognitive impairment score on the BIMS. Both residents had guardians and received their last COVID-19 immunization on November 11, 2022. There was no documentation indicating that they were offered the COVID-19 booster for 2023/2024. During interviews, the Infection Preventionist (IP) confirmed that both residents had a COVID infection in November 2023, which initially made them ineligible for the booster at that time. However, the facility's physician indicated that the residents would have been eligible to receive the COVID-19 immunization 90 days after testing positive. Despite this, there was no documentation that the residents were offered the immunization in 2023/2024, leading to the deficiency noted in the report.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notices of transfer for two residents, Resident #19 and Resident #37, as required. Resident #19, who was cognitively intact and their own decision-maker, was transferred to the hospital on three occasions without receiving a written notice of transfer. Interviews with facility staff, including a social worker, registered nurse, and assistant director of nursing, confirmed that the only paperwork provided during these transfers included a Continuity of Care Document, face sheet, and a petition to psychiatric services, but not a written transfer notice. Despite an email from the Nursing Home Administrator indicating that transfer notices could be found in the electronic medical record system, no such documentation was located. Similarly, Resident #37, who had moderate cognitive impairment and was their own decision-maker, was transferred to the hospital without receiving a written notice of transfer. The resident had been readmitted after a hospitalization for urosepsis, and no written notice was found for the June hospitalization. Interviews with the Director of Nursing and Clinical Support Nurse revealed that process changes were occurring around that time, which may have contributed to the oversight. Despite requests for documentation, no further documents were submitted before the survey exit.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to two residents upon their transfer to the hospital. Resident #19, who was cognitively intact and their own decision-maker, was transferred to the hospital multiple times without receiving the required written notice. Interviews with the social worker, registered nurse, and assistant director of nursing confirmed that the only paperwork provided during these transfers included a Continuity of Care Document, face sheet, and other specific documents, but not the bed hold policy. The nursing home administrator indicated that residents are provided the bed hold policy upon admission, but there was no documentation to support that Resident #19 received this notice during any of their hospital transfers. Similarly, Resident #37, who had moderate cognitive impairment and was their own decision-maker, was readmitted to the facility after hospitalizations without receiving a written notice of the bed hold policy. Although a notice for a previous hospitalization was submitted, there was no documentation for the June hospitalization. Interviews with the clinical support nurse and director of nursing revealed that process changes were occurring around that time, which may have contributed to the oversight. No further documentation was provided before the survey exit, indicating a lapse in the facility's procedure for notifying residents of the bed hold policy during hospital transfers.
Failure to Provide Treatment for Resident's Burn
Penalty
Summary
The facility failed to thoroughly assess or provide treatment for a hot liquid burn for a resident, resulting in the potential for medical complications. The resident, who had a history of cerebral infarction, heart failure, and other medical conditions, spilled mild temperature beverages on her lap during dinner. Initial assessments noted mild redness with no blistering, and the resident requested Tylenol for mild discomfort. However, subsequent observations revealed open areas on the resident's thighs, which were not attributed to the spill by the Director of Nursing (DON), who claimed they were due to scratching. The DON could not provide documentation of required skin assessments or any treatment orders for the burn or open areas. Interviews with staff and the resident indicated that blisters had developed after the spill, and no treatments were applied to the affected areas. A Certified Nursing Aide (CNA) reported observing blisters and redness and communicated this to nursing management and the Nursing Home Administrator. Despite these observations, the resident's medical records did not show any treatment or medication orders for the burn, nor were there any photographs of the affected areas. This lack of documentation and follow-up care highlights the facility's failure to provide appropriate treatment and care according to orders and the resident's needs.
Failure to Prevent Falls Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent accidents by not adhering to the care plan for a resident with a history of falls. The resident, who had multiple medical conditions including a history of falls, was left unattended in the shower by a certified nursing aide. The resident fell off the shower chair while reaching for a washcloth, resulting in a laceration on the forehead that required hospital treatment and stitches. The resident stated that she had not requested privacy during the shower, contradicting the aide's assumption that privacy was desired. The Director of Nursing and a registered nurse confirmed that the resident was left alone in the shower, despite being a known fall risk. The certified nursing aide admitted to leaving the resident unattended based on an assumption of privacy, acknowledging awareness of the resident's fall risk. The aide received re-education following the incident, emphasizing that residents with a history of falls should not be left alone during shower care.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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