Westland, A Villa Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Westland, Michigan.
- Location
- 36137 West Warren, Westland, Michigan 48185
- CMS Provider Number
- 235332
- Inspections on file
- 34
- Latest survey
- September 4, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Westland, A Villa Center during CMS and state inspections, most recent first.
Two residents reported that shower beds and rooms were not clean, leading them to avoid showers and opt for bed baths. Observations confirmed unsanitary conditions, including standing brown water, residue, and debris on a shower bed. Staff interviews indicated that cleaning protocols were not consistently followed, despite the availability of cleaning supplies and established policies.
A resident dependent on staff for transfers, with a history of hemiplegia and bipolar disorder, reported that staff were rough during wheelchair transfers, causing arm pain. The resident expressed anxiety about reporting the incidents. Observation showed the resident held one hand tightly to their chest, but no visible skin impairments were present at the time. The facility did not thoroughly assess or determine the root cause of the reported skin impairment.
A resident with a history of bipolar disorder, self-harm, and repeated 911 calls did not receive appropriate medically related social services. Despite multiple incidents of agitation, self-injury, and frequent emergency calls, there was no documented follow-up or intervention from social services, and care plans were not updated to address escalating behaviors. Facility staff, including the DON and Social Services Director, were unaware of the resident's self-harming actions and did not assess or address the root causes of the behaviors.
A resident's controlled medication was misappropriated when an LPN falsified the shift inventory records, started a new inventory sheet with incorrect counts, and removed the previous inventory documentation. The discrepancy was not immediately detected during the shift change count, as the oncoming LPN did not verify the new inventory against the previous one, contrary to facility policy. The missing medication was only discovered when the oncoming nurse attempted to administer it later, and the resident did not report any issues with pain management.
The facility failed to ensure residents' rights to receive unopened and private mail, as reported by two residents during a group interview. Residents stated their mail was sometimes delivered opened, with one resident receiving an opened personal letter. The Activities Director confirmed that the business office opened mail if the facility's name was on it, contrary to the facility's policy that staff should not open mail without resident permission.
The facility failed to maintain a clean and homelike environment, with issues such as clogged toilets, dusty fans, and soiled floors. Additionally, two residents reported missing personal property, specifically socks, which were not adequately addressed. The facility's policies on cleanliness and personal belongings were not upheld.
The facility did not complete the required 12 hours of annual in-service education for five CNAs. Despite efforts by the DON to contact a third-party education company for records, the necessary documentation was not provided by the end of the survey. The facility's policy outlines essential training topics, but the deficiency indicates non-compliance with these guidelines.
The facility failed to maintain cleanliness in the exterior dumpster area, as observed during a survey with the Dietary Manager. Several bags of trash were found on the ground around the dumpsters, with loose trash items accumulating between and along the sides. The maintenance department is responsible for cleaning this area. The facility's policy requires dumpsters to be kept closed and free of surrounding litter, but this was not adhered to, potentially affecting all residents, staff, and visitors.
The facility failed to maintain proper infection control practices, including the storage of nebulizer masks for two residents and the cleaning of blood pressure cuffs. Nebulizer masks were left uncovered, and LPNs did not clean equipment between residents. The DON acknowledged these lapses, and the facility's infection control program was found lacking in documentation and staff education.
The facility failed to complete necessary PASARR Level II evaluations for four residents with mental illness or intellectual disabilities. One resident with PTSD and Bipolar Disorder, another with Schizoaffective Disorder, and two others with significant cognitive impairments did not have the required evaluations or exemption letters in their records, despite facility policy requiring such assessments.
The facility failed to serve food in a palatable manner and at the preferred temperature for several residents. A resident reported the food as horrible with no input on the menu, while another found the food always cold and preferences ignored. A lunch tray temperature test showed lukewarm food, and a pureed meal was left untouched due to poor taste. The dietary manager and administrator acknowledged the issues, despite the facility's policy requiring appetizing temperatures.
A resident with multiple health issues, including Schizophrenia and Morbid Obesity, did not have regular care conferences as scheduled, leading to unmet needs and concerns. The resident, who is cognitively intact and dependent on staff for mobility, expressed that their concerns were ignored. The facility's policy requires resident participation in care planning, which was not adhered to.
A resident with Down Syndrome and severely impaired cognition was observed in a hallway with their tube feeding equipment exposed, compromising their dignity and privacy. Despite the facility's policy on maintaining dignity, the resident's stomach and tubing were visible to passersby, which the DON acknowledged should not have occurred.
The facility failed to ensure a call light was within reach for a resident with Alzheimer's and muscle weakness, observed multiple times with the call light out of reach. Additionally, another resident, who is 6'5" and 450 pounds, was not provided with a properly fitting wheelchair, causing discomfort and mobility issues. Despite being measured for a better chair, no suitable wheelchair was provided, and the facility was reluctant to cover the cost, as noted by the local Ombudsman.
A facility failed to maintain accurate advance directive information for a resident with impaired cognition, resulting in a discrepancy between the resident's stated preferences and documented code status. The LPN struggled to locate the correct information, and the process for updating records was not effectively implemented.
The facility failed to report and investigate a verbal altercation between two residents, leading to a room change for one resident without proper documentation. The incident involved a resident with Schizoaffective disorder, who verbally abused and threatened their roommate. The Director of Nursing was aware of the incident, but no formal investigation was documented, and the Nursing Home Administrator was not informed, contrary to facility policy.
A facility failed to accurately complete a PASARR for a resident with Bipolar Disorder and Weakness. The resident's medical record showed intact cognition and required assistance with mobility, while being on multiple psychotropic medications. However, the PASARR screening incorrectly indicated no mental illness diagnosis or treatment, and no updated PASARR or Level II screening was found. The issue was attributed to a social worker's leave, resulting in incomplete tasks.
The facility failed to implement care plan interventions for two residents. One resident, with multiple diagnoses, was often left unsupervised without required floor mats, contrary to their care plan. Another resident with an ankle tether had no care plan for skin checks under the device, despite it impeding therapy. Staff acknowledged the lack of documentation and care planning.
The facility failed to update care plans for two residents, leading to deficiencies in care. One resident, with multiple diagnoses including dysphagia, was placed on an NPO order, but their care plan was not updated. Another resident with PTSD had a care plan lacking individualized interventions. The social worker acknowledged the need for revisions.
The facility failed to provide adequate ADL assistance for two residents. One resident was observed with poor hygiene and reported not receiving regular showers or grooming. Another resident, requiring 1:1 feeding assistance due to Dysphagia and Muscle Weakness, was left to eat independently without meal setup. The facility's policy on ADLs was not followed, as residents did not receive necessary services to maintain good nutrition and hygiene.
A resident with Critical Illness Myopathy and Muscle Weakness, requiring staff assistance and having intact cognition, was not scheduled for a timely follow-up ophthalmology appointment despite recommendations due to retinal bleeding. The resident was unaware of the appointment status, and the Unit Secretary cited difficulties due to the resident's hospital visits. The DON noted that implementing ancillary service recommendations is a process, and the facility did not provide a policy on ancillary services.
A resident known for throwing and breaking plates was provided with a breakfast tray containing glass plates and regular utensils, contrary to instructions for paper products only. An LPN confirmed the need for paper products for safety, and the Dietary Manager attributed the error to a new staff member. The facility's accident policy did not address this issue.
A facility failed to obtain physician orders for colostomy care for a resident, who reported their colostomy bag had not been changed in two months. The resident, admitted with multiple diagnoses and cognitively intact, had a medical record indicating an ostomy bag but lacked a physician's order for its care. The DON confirmed the necessity of such an order for proper nursing care.
The facility failed to ensure nurse staffing information was readily accessible, with incomplete postings observed on multiple occasions. The scheduler delayed completing the forms due to potential staffing changes, resulting in missing information for certain shifts. Additionally, the facility did not maintain access to 18 months of staff postings, as some records were shredded by a third party.
A facility failed to review, act upon, and document medication regimen irregularities for a resident with multiple diagnoses, including Heart Failure and Depression. Despite a pharmacist noting irregularities, the facility did not provide the necessary documentation or physician response. Additionally, the facility's policy lacked guidance on reviewing pharmacy reports.
A resident with multiple diagnoses, including Morbid Obesity and Schizophrenia, was observed with yellow and discolored teeth. Despite a recommendation for a dental clinic visit for x-rays, the resident was not seen by dentistry due to sleeping, and no follow-up appointment was scheduled. The facility's policy did not address ensuring timely follow-up on dental recommendations.
A resident's call light system was not functioning properly, as the light outside the room did not alert staff to the resident's need for assistance. The resident reported the issue had persisted for some time, and there were no work orders for repairs. The facility's policy mandates functional call lights and prompt reporting of defects, which was not followed.
A resident with contracted fingers was not provided with a hand splint as ordered by occupational therapy. The splint was found unused, and there was no physician's order or care plan documentation for it. The resident's cognition was not assessed, and the restorative aide was unaware of the splint. The facility's policy on integrating therapy recommendations into care plans was not followed.
A resident was found with unauthorized medications in their room, including Fluticasone nasal spray and other medications without proper orders for self-administration. The resident's cognitive status was not assessed, and the facility's policy requires an interdisciplinary team evaluation for self-administration. An LPN noted the resident's confusion and the DON confirmed the need for proper orders and assessments.
The facility failed to provide timely lab services for two residents, leading to delays in health assessments. One resident had an invalid dilantin level and no documentation of a required Phenytoin trough level, while another had missing lab results and out-of-range values. The facility's policies on timely lab services were not followed.
A resident with schizophrenia and PTSD physically assaulted another resident over a clothing dispute, resulting in hospitalization for the victim. The aggressor had a history of behavioral issues that were not addressed in their care plan, and the facility failed to document and intervene appropriately, leading to the altercation.
A resident with multiple medical conditions fell from a full body mechanical lift, marking the fourth such incident. The resident experienced severe pain and required hospital evaluation. The facility failed to document the incident properly, and unsafe transfer practices were not reported. Additionally, the resident's wheelchair was inadequately cushioned, and the armrest was loose, contributing to the risk of injury.
The facility failed to maintain a clean and homelike environment, with issues such as a wall patch with dust, urine odor in hallways, and mold in a toilet bowl. Observations included gnats around food, a stopped wall clock, and cigarette butts in the smoking area. These deficiencies were noted despite the facility's policy on identifying safety risks and environmental hazards.
A resident with intact cognition and a medical history of Major Depressive Disorder, Asthma, Respiratory Failure, and Muscle Weakness was found in a room with stained privacy curtains. The resident had previously reported the issue to housekeeping. The Housekeeping Supervisor confirmed monthly cleaning of curtains, and the Nursing Home Administrator acknowledged the expectation for a clean environment, as per the facility's Resident Rights policy.
The facility failed to update a PASARR screening for a resident diagnosed with Anxiety and Schizophrenia who remained in the facility for more than 30 days. The required updated screening was not conducted, and the responsible social worker was no longer with the company. The facility's policy on annual and significant change PASARR screenings was not followed.
A resident's PICC line dressing was not changed or dated as required. The resident reported that the dressing had not been changed since hospital discharge. The LPN planned to call for an order to remove the PICC line, and the DON confirmed that an order for regular dressing changes should have been entered per policy.
Failure to Maintain Clean and Sanitary Shower Beds
Penalty
Summary
The facility failed to maintain clean and sanitary shower beds, as evidenced by observations, interviews, and record review. Two residents reported that the shower beds and shower rooms were not clean, with one resident providing photographic evidence of the unsanitary conditions on multiple days. Both residents stated they had been opting for bed baths instead of showers due to the lack of cleanliness. During an observation, a shower bed was found with standing brown water in the crevices, white residue, and brown flakes on both the covering and the frame. Staff interviews revealed that CNAs are responsible for cleaning the shower beds after each use, and the Infection Control Preventionist confirmed that cleaning should occur between each patient use, with a deep clean performed during the night shift. Cleaning supplies, including scrub brushes and disinfectant, were reportedly available in every shower room. A review of the facility's policy indicated that equipment surfaces should be cleaned according to manufacturer instructions, but the observed and reported practices did not align with these requirements.
Failure to Assess and Determine Root Cause of Skin Impairment During Transfers
Penalty
Summary
The facility failed to thoroughly assess and determine the root cause of a skin impairment for a resident reviewed for skin management. During an unannounced onsite investigation, a resident with hemiplegia and bipolar disorder, who was dependent on staff for transfers, reported that staff were rough when transferring them to a wheelchair, causing pain to their arms. The resident expressed fear and anxiety about reporting these incidents, stating they did not want to get anyone in trouble. Observation revealed the resident held their left hand tightly against their chest, with uncertainty about their ability to straighten the arm, while the right arm was freely movable. At the time of observation, no visible bruising or skin impairments were noted on the arms. The clinical record review confirmed the resident's dependency on staff for transfers and intact cognition.
Failure to Provide Medically Related Social Services for Resident with Self-Harm and Behavioral Issues
Penalty
Summary
The facility failed to provide medically related social services to a resident with a history of self-harm, mood disorders, and repeated 911 calls. The resident, who had diagnoses including hemiplegia, hemiparesis, and bipolar disorder, expressed dissatisfaction with care, reported thoughts of suicide, and had multiple documented incidents of agitation, resisting care, and self-harming behaviors such as hitting themselves and banging their head against the wall. Despite these behaviors and repeated emergency calls, there was no evidence of follow-up or intervention from the social services department after an initial note in March, nor was there documentation of assessment or discussion regarding the root causes of the resident's actions. The resident's clinical record showed frequent calls to 911 for various complaints, resulting in multiple hospital transfers, but there was no documentation of any attempt by staff to determine the underlying reasons for these calls. Psychiatric evaluations were conducted, but they did not address the repeated emergency calls or incidents of self-harm. The care plan for the resident was not updated to reflect new or escalating behaviors, and no new interventions were implemented after the resident exhibited self-harming actions. Interviews with facility staff, including the Administrator, DON, and Social Services Director, revealed a lack of awareness and communication regarding the resident's suicidal ideation and self-harming behaviors. The Social Services Director was unaware of these incidents and had not provided follow-up or interventions. The Administrator acknowledged that there should have been documented follow-up and interventions after the resident's return from the hospital, but none were present in the record.
Failure to Prevent Misappropriation of Resident Medication Due to Inadequate Controlled Substance Inventory Procedures
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's medication when an LPN diverted controlled substances by falsifying the shift inventory records. The LPN initiated a new Controlled Substance Shift Inventory and recorded an incorrect number of medication blister packs, which allowed the medication to be removed without immediate detection during the shift change count with another LPN. The previous inventory sheet and pharmacy controlled substance records were missing at the time, and the discrepancy was only discovered when the oncoming nurse attempted to retrieve the medication for the resident a few hours later. The missing inventory sheet was later found in the shred box and revealed a discrepancy in the count compared to the new inventory. The DON confirmed that the oncoming nurse did not verify the new inventory against the previous one, as required by facility policy, and the oncoming LPN acknowledged not following the standard procedure for handling inventory sheets. The resident involved did not report any concerns about missing medication or pain management and was observed to be comfortable, with no overt signs of pain. Facility policies required a thorough reconciliation of controlled substances at shift change and defined misappropriation as the wrongful use of a resident's belongings or money without consent.
Failure to Ensure Privacy in Mail Delivery
Penalty
Summary
The facility failed to ensure residents' rights to receive unopened and private mail delivery, as evidenced by the experiences of two residents who attended a resident group interview. During the interview, residents reported that their mail was sometimes delivered opened. One resident specifically mentioned receiving a personal letter from their sister that was opened without their understanding of why this occurred. The group further explained that facility staff would open mail if they suspected it contained a check. The Activities Director (AD) confirmed that the mail is received from the business office and delivered to residents by the activities department. The AD stated that the activities department does not open residents' mail, but the business office has opened mail before handing it over for delivery. The AD expressed discomfort with delivering opened mail, citing legal concerns. The Business Office Manager admitted to opening residents' mail if the facility's name appeared alongside the resident's name. The facility's policy on Resident Rights, dated 1/28/2017, clearly states that facility staff should never open residents' mail unless permitted by the resident, highlighting a breach in policy compliance.
Deficiencies in Environmental Cleanliness and Personal Property Protection
Penalty
Summary
The facility failed to maintain a clean, homelike, and odorless environment for its 194 residents. Observations revealed a toilet near nurse station one was repeatedly clogged with toilet paper, feces, and urine, emitting a strong odor. Additionally, a fan in a resident's room was covered in dust, and multiple resident council meeting notes from December 2024 to February 2025 indicated concerns about rooms not being cleaned daily. Interviews with staff revealed that maintenance was responsible for unclogging toilets, but a broken toilet required new bolts for repair. The facility's policy emphasized providing a clean and homelike environment, which was not upheld. Further observations on March 18, 2025, showed that the flooring in a resident's room was soiled with stains, sticky, and dull, with a buildup of grime in the bathroom. The over-bed table had exposed particle board, making it difficult to clean. Another room had a black, gummy substance around floor tiles, and a resident complained of old urine stains and odors, which were not addressed. The facility's policy stated that residents should have a clean, sanitary, and orderly environment with pleasant scents, which was not maintained. The facility also failed to protect the personal property of two residents, R3 and R47. R3 reported missing socks despite marking them, and the facility did not provide a personal inventory sheet. R47 also reported missing socks, which were labeled, and informed staff about the issue. The Environmental Services Director stated that missing items are replaced if a receipt is provided, or they refer to the personal inventory sheet, which was not available. The facility's policy encouraged residents to use personal belongings, but this was not effectively supported.
Failure to Complete Annual In-Service Education for CNAs
Penalty
Summary
The facility failed to complete the required 12 hours of annual resident care in-service education performance reviews for five Certified Nurse Aides (CNAs), identified as Z, AA, BB, CC, and DD. On the specified date, a request was made for these performance reviews, but the Director of Nursing (DON) reported that they were in the process of contacting a third-party education company to obtain the necessary staff education records. Despite this effort, the DON was unable to provide an estimated time for when the education in-services would be available, and the request for the CNAs' education was not fulfilled by the end of the survey. The facility's policy, titled 'Training Requirements Guideline' dated May 29, 2020, outlines the purpose of informing and guiding center leadership about training requirements and their role in developing, implementing, and maintaining an effective training program for all staff. The policy specifies that training topics must include effective communication, resident rights, abuse prevention, conflict resolution, infection control, and other essential areas. The failure to provide the required in-service education indicates a deficiency in adhering to these training guidelines.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the exterior dumpster area in a clean manner, as observed during a survey. On March 8, 2025, at 9:30 AM, an inspection of the two exterior dumpsters was conducted with the Dietary Manager (DM) O. Several bags of trash were found on the ground in front of the dumpsters, on the side, and behind the dumpsters. Additionally, there was an accumulation of loose trash items between and along the sides of the dumpsters. DM O indicated that the maintenance department is responsible for cleaning the dumpster area. The facility's undated policy on Food-Related Garbage and Rubbish Disposal states that outside dumpsters provided by garbage pickup services should be kept closed and free of surrounding litter. This deficiency in maintaining cleanliness in the dumpster area had the potential to affect all residents, staff, and visitors.
Infection Control Deficiencies in Nebulizer Mask Storage and Equipment Cleaning
Penalty
Summary
The facility failed to ensure proper infection control practices, particularly in the storage of nebulizer masks for two residents and the cleaning of blood pressure cuffs. Observations revealed that one resident's nebulizer mask was left uncovered on a cluttered nightstand and even on the floor, while another resident's nebulizer mask was similarly left uncovered on a nightstand without being stored in a bag or placed on a barrier. The Director of Nursing (DON), who also served as the interim Infection Preventionist, acknowledged that nebulizer masks should be stored in plastic bags after use, but this practice was not followed. Additionally, during a medication pass, an LPN was observed taking vital signs of three residents without cleaning the equipment before or after use. Another LPN also failed to clean a blood pressure cuff after use. The facility's policy requires that reusable medical equipment be cleaned with bleach wipes between residents, but this was not adhered to. The DON confirmed that the expectation is for cleaning to occur between each resident. The facility's infection control program was also found lacking, with missing documentation and insufficient staff education on infection control practices.
Failure to Complete PASARR Level II Evaluations
Penalty
Summary
The facility failed to complete the necessary Preadmission Screening and Resident Review (PASARR) Level II evaluations for four residents who were identified as needing further assessment due to mental illness or intellectual disabilities. Resident R44 was admitted with diagnoses of PTSD and Bipolar Disorder, and their PASARR screening indicated the presence of mental illness, yet no Level II evaluation was found in their medical record. Similarly, Resident R177, who had a PASARR with a 30-day exemption, did not have an updated PASARR on file. The facility's social worker acknowledged that some tasks were not completed timely due to a staff member's leave. Resident R4, with diagnoses including Schizoaffective Disorder and Major Depressive Disorder, had a severely impaired cognition score and was dependent on staff for all activities of daily living, yet lacked a Level II evaluation or a Dementia Exemption letter in their record. Resident R10, diagnosed with Bipolar Disorder and later Dementia, also had a severely impaired cognition score and required significant assistance, but their record did not contain a Level II evaluation or a Dementia Exemption letter. The facility's policy on PASARR guidelines emphasizes the need for annual evaluations and assessments upon significant changes, which were not adhered to in these cases.
Failure to Serve Palatable and Appropriately Tempered Food
Penalty
Summary
The facility failed to serve food in a palatable manner and at the preferred temperature for several residents, as observed and reported by both residents and surveyors. Resident R69 expressed dissatisfaction with the food, stating it was horrible and that residents had no input on the menu. R154 reported that the food was always cold and that their preferences were not considered, as evidenced by receiving cold chicken noodle soup. R53 described the food as terrible, and a temperature test of a lunch tray revealed that the food was not served at appropriate temperatures, with items like pork cutlet and cheesy potatoes being lukewarm. R30, who was served a pureed meal, found the food unpalatable and left it untouched, stating it tasted unpleasant. The dietary manager and the administrator acknowledged the issues, with the dietary manager indicating that food temperature was based on resident preferences and the administrator stating that food should be palatable and served at the appropriate temperature according to the facility's policy. The facility's policy on food palatability and temperature guidelines was reviewed, noting that food should be served at appetizing temperatures and distributed quickly to residents. Despite these guidelines, the observations and resident interviews highlighted a failure to adhere to these standards, resulting in dissatisfaction with the food's palatability and temperature.
Failure to Conduct Regular Care Conferences
Penalty
Summary
The facility failed to conduct regular care conferences for a resident, identified as R133, who was admitted with multiple diagnoses including Morbid Obesity, stiffness in both hands, Muscle Weakness, Muscle Wasting and Atrophy, and Schizophrenia. Despite being cognitively intact and dependent on staff for bed mobility and transfers, R133 expressed difficulty in having their needs met, as their concerns were not being addressed. The medical record review indicated that care conferences were scheduled but not conducted on three specific dates. The facility's Social Worker acknowledged the oversight, and the facility's Resident Rights policy emphasizes the importance of residents participating in their person-centered care planning.
Failure to Maintain Resident Dignity During Tube Feeding
Penalty
Summary
The facility failed to maintain the dignity of a resident during tube feeding. On multiple occasions, the resident was observed sitting in a geri chair in the hallway with their tube feeding equipment exposed to passersby. The resident's shirt was lifted, exposing their stomach, tubing, and patch, which compromised their privacy and dignity. This was observed on two separate days, indicating a pattern of neglect in maintaining the resident's dignity during care. The resident involved had a diagnosis of Down Syndrome and was noted to have severely impaired cognition, requiring full assistance from staff for activities of daily living. Despite the facility's policy on maintaining dignity and privacy, the Director of Nursing acknowledged that the resident's stomach and tubing should not have been exposed in a public area. The facility's failure to adhere to its own policy on dignity and privacy resulted in the resident being treated without the respect and dignity they are entitled to.
Failure to Ensure Call Light Accessibility and Proper Wheelchair Fit
Penalty
Summary
The facility failed to ensure the call light was within reach for a resident, identified as R70, who was observed multiple times with the call light hanging out of reach above their bed. Despite being asked how they would use the call light, R70 indicated they did not know how to use it and mentioned they could holler loudly for assistance. The resident's medical record showed they were admitted with Alzheimer's Disease, Diabetes, and Muscle Weakness, requiring varying levels of assistance for activities of daily living. The facility's policy mandates that call lights be accessible to residents, but this was not adhered to, as evidenced by repeated observations of the call light being out of reach over several days. The Director of Nursing confirmed the expectation for call light accessibility, yet the issue persisted throughout the survey period. Additionally, the facility failed to provide a properly fitting wheelchair for another resident, R131, who was observed sitting in a wheelchair that was too low to the ground, causing discomfort and difficulty in mobility. R131, who is 6 foot 5 inches tall and weighs 450 pounds, expressed that the wheelchair was too small and low, making it hard to pedal and causing fatigue. Despite being measured for a better-fitting chair, no suitable wheelchair was provided. The Physical Therapy Manager expressed concerns about accommodating R131's size needs upon admission, and the resident had been using various inadequate seating devices, resulting in broken equipment. The Nursing Home Administrator was reluctant to provide a costly wheelchair, despite advocacy from the local Ombudsman, highlighting the facility's failure to accommodate the resident's needs adequately.
Failure to Update Resident's Advance Directive Information
Penalty
Summary
The facility failed to ensure that updated and accurate advance directive information was in place for a resident with moderate impaired cognition, who was admitted with diagnoses including Dementia, Muscle Weakness, and Schizophrenia. The resident's medical record indicated a Full Code status, yet a Do-Not Resuscitate (DNR) order was signed by the resident, a witness, and the resident's physician on different dates. Additionally, the resident expressed a preference not to receive life-sustaining treatment in the event of respiratory distress, which was not reflected in the medical record. The Licensed Practical Nurse (LPN) was unaware of the resident's current code status and had difficulty locating the binder containing this information, indicating a lack of proper communication and documentation. The Social Worker and Director of Nursing (DON) both indicated that nursing staff are responsible for updating the medical record when there is a change in code status. However, the process for ensuring these updates was not effectively implemented, as evidenced by the discrepancy between the resident's stated preferences and the documented code status.
Failure to Report and Investigate Verbal Altercation
Penalty
Summary
The facility failed to report and investigate a verbal altercation between two residents, R199 and R197. On March 17, 2025, R197 reported that R199 had verbally abused and threatened them and another roommate. Despite this incident, there was no documentation in R199's electronic medical record regarding the room change or the verbal altercation. The Social Worker confirmed that R199 was moved due to the altercation but acknowledged that no formal investigation was documented. The Director of Nursing (DON) was aware of the incident but admitted that the required note detailing the incident was not entered into the medical record. R199 was admitted to the facility with a diagnosis of Schizoaffective disorder, Bipolar Type, and had an intact cognition according to their Minimum Data Set (MDS) assessment. The care plan for R199 included monitoring for cognitive decline and administering psychotropic medications. The Nursing Home Administrator (NHA) was unaware of the room change and the incident, which was contrary to the facility's policy that mandates reporting such incidents to the administrator. The facility's policy on abuse requires immediate reporting and investigation of any suspected abuse, including verbal abuse, but this procedure was not followed in this case.
Failure to Accurately Complete PASARR for Resident
Penalty
Summary
The facility failed to accurately complete a Preadmission Screening and Resident Review (PASARR) for a resident, identified as R3, who was admitted with diagnoses of Bipolar Disorder and Weakness. The medical record review revealed that R3 had a Brief Interview for Mental Status score indicating intact cognition and required staff assistance with bed mobility and transfer. Despite being on medications such as Seroquel, Ativan, Zoloft, and Buspirone, the PASARR screening on file incorrectly indicated 'No' for questions regarding current diagnosis of mental illness, treatment for mental illness, and routine use of antipsychotic or antidepressant medications. The deficiency was further highlighted by the absence of an updated PASARR or Level II screening in R3's medical record. During an interview, Social Work T acknowledged that the previous social worker's leave resulted in incomplete tasks, including the timely update of R3's PASARR. The facility's policy on PASARR guidelines emphasizes the importance of ensuring individuals with mental illness and intellectual disabilities receive appropriate care and services, which was not adhered to in this case.
Failure to Implement Care Plan Interventions for Residents
Penalty
Summary
The facility failed to develop and implement appropriate care plan interventions for two residents, leading to deficiencies in their care. For one resident, who was admitted with diagnoses including Metabolic Encephalopathy, Muscle Weakness, End Stage Renal Disease, and Aphasia, the care plan required 1:1 supervision and the use of floor mats to prevent falls. However, observations revealed that the resident was often left unsupervised, without the required floor mats in place, and with soiled items left on the floor, indicating a lack of adherence to the care plan. Additionally, the resident was observed in situations that could lead to falls, such as being unsupervised in the bathroom, which was contrary to the care plan's interventions. Another resident, who was admitted with diagnoses including Pleural Effusion, Sepsis, and Weakness, was observed with an ankle tether monitoring device. The care plan did not include any interventions related to the monitoring or care of the skin under the ankle tether, despite the resident's report that the tether impeded their therapy and that no skin checks had been conducted. The facility's staff, including the Unit Manager and Director of Nursing, acknowledged the lack of documentation and care planning related to the ankle tether, which should have been addressed to prevent potential skin integrity issues.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure timely revisions of care plans for two residents, R4 and R44, leading to deficiencies in their care. R4, who was admitted with diagnoses including Cerebral Infarction, Schizoaffective Disorder, Depression, seizures, and Oral Phase Dysphagia, was observed in a wheelchair without a lunch tray. It was revealed that R4 was placed on a Nothing by Mouth (NPO) order due to increased difficulty with their pureed diet. However, the care plan was not updated to reflect this change in dietary status, despite the physician's order being placed the previous day. For R44, who was admitted with Post-Traumatic Stress Disorder (PTSD) and Bipolar Disorder, the care plan lacked individualized interventions related to PTSD. R44 expressed having past trauma from personal family affairs and loss, yet the care plan only included a general focus on potential ineffective coping without specific strategies. The social worker acknowledged the need to revise and individualize R44's care plan, indicating it was incomplete and inappropriate.
Failure to Provide Adequate ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, R32 and R177. R32 was observed multiple times over several days with unkempt greasy hair, long nails with an unknown brown substance underneath, and facial hair, indicating a lack of regular bathing and grooming. Despite being cognitively intact, R32 reported not receiving regular showers or grooming, and the Unit Manager and Director of Nursing (DON) were made aware of the resident's appearance but did not ensure appropriate hygiene care was provided. R177, who was diagnosed with Dysphagia and Muscle Weakness, was observed eating independently despite having a diet order requiring 1:1 feeding assistance. On one occasion, R177 was found with a breakfast tray that had not been set up, and the resident reported not receiving help with eating. The LPN confirmed that R177 required assistance with eating, and the DON indicated that R177 was on a red napkin program, which required staff to set up meals for the resident. The facility's policy on ADLs stated that residents unable to carry out ADLs independently should receive necessary services to maintain good nutrition and hygiene, which was not adhered to in these cases.
Failure to Schedule Timely Ophthalmology Appointment
Penalty
Summary
The facility failed to schedule a follow-up ophthalmology appointment in a timely manner for a resident who required specialized eye care. The resident, who was admitted with diagnoses of Critical Illness Myopathy and Muscle Weakness, had intact cognition and required staff assistance with bed mobility and transfers. An in-house vision group recommended that the resident see an ophthalmologist due to retinal bleeding in both eyes. However, the resident reported not being informed about the appointment status or any delays. The Unit Secretary acknowledged the difficulty in keeping up with the appointment due to the resident's hospital visits. The Director of Nursing mentioned that implementing recommendations from ancillary services is a process. The facility did not provide a policy on ancillary services by the end of the survey.
Failure to Provide Accident-Free Environment for Resident
Penalty
Summary
The facility failed to maintain an accident-free environment for a resident identified as R177. During an observation, R177 was found in their room with a breakfast tray that included glass plates, regular cups, and silverware, despite a clear instruction on the tray ticket indicating that R177 should only have paper products. This instruction was highlighted in capital letters due to R177's known behavior of throwing and breaking plates, which poses a safety risk. Licensed Practical Nurse (LPN) W confirmed that R177 should have paper products for safety reasons but was unsure how the regular plates ended up on the tray. Dietary Manager (DM) O also confirmed that R177 was not supposed to have regular plates and attributed the error to a new person on the tray line. The facility's policy on accidents did not address the use of paper products for residents with such behaviors.
Failure to Obtain Physician Orders for Colostomy Care
Penalty
Summary
The facility failed to obtain physician orders for colostomy care for a resident who required such services. The resident, who was cognitively intact, reported that their colostomy bag had not been changed in two months. The resident was admitted with diagnoses including Muscle Weakness, Heart Failure, Depression, and Paroxysmal Atrial Fibrillation. A review of the resident's medical record showed a Quarterly Minimum Data Set assessment indicating the presence of an ostomy bag, but no physician's order for its care was found. The Director of Nursing acknowledged that there should have been an order to guide the nursing staff in providing the necessary care.
Incomplete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was readily accessible for all residents, families, and visitors. On multiple occasions, the staff postings were observed to be incomplete, lacking information for the midnight shift on one day and for both the afternoon and midnight shifts on another day. The scheduler explained that she completes the form once she knows the staff for the shift, indicating a delay in posting due to potential changes in staffing. This practice resulted in incomplete postings that were not available at the start of each shift as required. Additionally, a review of the facility's staff postings over the past 18 months revealed that the facility did not maintain access to these records, as some months were sent to be shredded by a third party. The scheduler mentioned that when she was not at work, the charge nurse was responsible for completing the forms, which may have contributed to the inconsistency in maintaining complete records. The facility's policy requires that staffing information be posted daily and updated as changes occur, but this was not consistently followed, leading to the deficiency.
Failure to Document and Act on Medication Irregularities
Penalty
Summary
The facility failed to ensure that medication regimen irregularities were reviewed, acted upon, and documented for a resident identified as R32. The resident was admitted with diagnoses including Muscle Weakness, Heart Failure, Depression, and Paroxysmal Atrial Fibrillation, and was noted to be cognitively intact. During a review of R32's monthly medication regimen, irregularities were identified by the pharmacist on 11/24/24. However, when a request was made on 3/20/25 for the irregularities report and the physician's response, the facility did not provide the requested documentation by the end of the survey. Additionally, a review of the facility's Physician Services policy revealed that it did not outline the process for reviewing pharmacy reports following medication regimen reviews. This lack of documentation and policy guidance contributed to the deficiency in managing medication regimen irregularities for the resident.
Failure to Schedule Recommended Dental Services for a Resident
Penalty
Summary
The facility failed to schedule recommended dental services for a resident, identified as R133, who was observed with yellow and discolored teeth. R133, who was admitted with diagnoses including Morbid Obesity, Stiffness of both hands, Muscle Weakness, Muscle Wasting and Atrophy, and Schizophrenia, was cognitively intact and dependent on staff for bed mobility and transfers. The resident had a dental exam on 5/29/24, during which it was recommended that they be brought to the dental clinic for x-rays at their next visit. However, on 7/2/24, the resident was not seen by dentistry because they were sleeping, and no further appointment was scheduled. The Social Worker indicated that the medical records scheduler is responsible for making outside appointments, and an appointment should have been scheduled. The Director of Nursing acknowledged that dental recommendations are expected to be followed. The facility's Routine and Emergency Dental Services policy did not address the process for ensuring dental recommendations are followed in a timely manner.
Deficiency in Call Light Functionality
Penalty
Summary
The facility failed to ensure a functional call light system for a resident, identified as R61, which was observed during a survey. On multiple occasions, the call light inside R61's room was lit, indicating a request for assistance, but the corresponding light outside the room, which alerts staff, was not operational. R61 reported that the call light had been malfunctioning for some time and expressed concerns about the timeliness of staff responses to call lights. Upon review, there were no work orders for repairs in R61's room, indicating a lack of action to address the issue. The Director of Nursing and Environmental Services Assistant later confirmed the call light had been repaired, but the date of repair was not recalled. The facility's policy requires that call lights be functional at all times and that defective call lights be reported promptly, which was not adhered to in this case.
Failure to Implement Hand Splint for Resident
Penalty
Summary
The facility failed to implement a hand splint for a resident, identified as R500, who was observed with contracted fingers on their right hand. The hand splint, intended to provide proper alignment and prevent contractures, was found lying unused on the floor. R500 indicated that they were supposed to wear the splint but had never been shown how to apply it. A review of R500's records showed no physician's order or care plan documentation for the hand splint, despite occupational therapy having ordered it. The resident's cognition was not assessed, as indicated by the Minimum Data Set. The Physical Therapy director confirmed that occupational therapy had treated R500 and ordered a wrist hand finger orthosis, but no order was placed in the electronic medical record (EMR). The Director of Nursing, acting as the restorative nurse, stated that the restorative aide was unaware of the splint. The facility's policy on restorative nursing services emphasizes individualized care plans and integrating therapy recommendations, which was not followed in this case. The lack of documentation and communication led to the failure to provide the necessary care for R500's condition.
Improper Medication Storage for a Resident
Penalty
Summary
The facility failed to properly store medications for a resident, identified as R500, who was observed with two bottles of Fluticasone nasal spray on their nightstand and a clear plastic bag containing six medication bottles in their room. The medications included Colace, Certizine, and Meloxicam, with three bottles having illegible labels. R500's medical record did not contain orders for self-administration or to leave medications at the bedside, nor were there orders for Colace, Certizine, or Meloxicam. R500 was admitted with a diagnosis of polyarthritis, and their cognitive status was not assessed as indicated by the Minimum Data Set. LPN A acknowledged that R500 sometimes becomes confused and should not have medications in their room, but they were left there to avoid confrontation. The Director of Nursing confirmed that medications should not be in a resident's room without a physician's order and an assessment confirming the resident's ability to self-administer. The facility's policy requires an interdisciplinary team to assess a resident's cognitive and physical abilities before allowing self-administration of medications, and any unauthorized medications found at the bedside should be removed by the nurse in charge.
Failure to Ensure Timely Laboratory Services
Penalty
Summary
The facility failed to ensure timely completion of laboratory tests for two residents, resulting in a delay in health assessments. Resident R901, who was admitted with diagnoses of Diabetes and High Blood Pressure, had a physician order for Phenytoin trough levels every three months. However, the lab results showed an invalid dilantin level, and the last documented lab was a CBC in July 2024. Despite daily administration of Phenytoin, there was no documentation of a dilantin level in the hospital records from October 2024, and the facility could not provide this documentation during the survey. Resident R902, admitted with a history of Stroke and Diabetes, had a lab order for a CBC and CMP in May 2024, but the results were not documented in the electronic medical record. A subsequent lab in December 2024 showed twenty lab values out of range. The Director of Nursing confirmed that the labs ordered in May were not completed, and the facility was not notified of the missed labs. The facility's policies emphasize the importance of timely and accurate lab services, but these were not adhered to, leading to the deficiencies noted.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, resulting in a serious altercation between two residents. Resident R904, who had intact cognition and was diagnosed with end-stage renal disease, was involved in a physical altercation with Resident R903, who also had intact cognition and was diagnosed with schizophrenia and PTSD. The altercation began over a dispute about clothing, leading to R904 being hospitalized with a right eye fracture and other injuries after being punched and kicked by R903. Prior to the incident, R903 exhibited several behavioral issues, including cursing, expressing anger, and threatening others, which were documented but not adequately addressed in their care plan. Despite a history of hallucinations, delusions, and anger triggers, R903's care plan lacked mention of their psychiatric diagnosis or behaviors. The facility's failure to document and address these behaviors contributed to the escalation of the situation, as protective interventions were not implemented. Interviews with staff and residents revealed that the altercation was witnessed by others, and the facility's response was delayed. The Director of Nursing confirmed that there were no progress notes or incident reports for R903's behaviors on the days leading up to the incident, indicating a lack of proper documentation and intervention. The facility's policy on abuse prevention was not effectively implemented, as the needs and vulnerabilities of the residents were not adequately assessed or addressed to prevent the altercation.
Failure to Prevent Resident Fall from Mechanical Lift
Penalty
Summary
The facility failed to prevent an accident involving a resident, identified as R905, who experienced a fall from a full body mechanical lift. The incident was reported by a triage nurse at the hospital, where R905 presented with acute pain after falling onto their back and legs. This was reportedly the fourth occurrence of such an incident with the mechanical lift at the facility. Despite the resident's complaints of severe pain and the need for emergency medical attention, there was no documentation of the incident in the facility's records, other than a progress note by LPN F. The resident, R905, has a medical history that includes peripheral vascular disease, kidney failure, diabetes, stroke, paraplegia, anxiety, depression, and asthma. They are dependent on staff for bed mobility, transfers, and toileting. During the incident, R905 reported being lifted out of their wheelchair by CNA E using the mechanical lift when they suddenly fell back into the wheelchair, causing severe pain. The resident's wheelchair was observed to have a gap between the cushion and the seat, which may have contributed to the severity of the impact. CNA E admitted to not reporting the unsafe transfer practices to the nursing staff or therapy services, and the facility's mechanical lifts were noted to be short on batteries. Additionally, the right armrest of R905's wheelchair was found to be loose, which was not reported to maintenance. The facility's policy on safety and supervision was not followed, as there was no incident report or therapy referral made for R905 following the incident. The Nursing Home Administrator and Director of Nursing acknowledged the lack of appropriate documentation and intervention following the incident.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a clean and homelike environment, affecting multiple rooms and common areas. Observations included a wall patch with white dust and a hole in one room, a pungent urine odor in the hallway near several rooms, and closet cabinet drawers hanging down in another room. Additionally, a resident reported concerns about a water dispenser with a black substance and hard water stains, as well as numerous cigarette butts in the smoking area. The smoking area was observed to have over fifty cigarette butts on the ground. Further observations revealed gnats around an over bed table with food items in one room, a stopped wall clock, and flies and gnats around food in another room. The cove base outside a bathroom door was peeled away, revealing a hole in the wall with sheetrock debris on the floor. A black substance resembling mold was found in the toilet bowl of another room. These deficiencies were noted despite the facility's policy on identifying safety risks and environmental hazards through employee training, monitoring, and reporting processes.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean, homelike environment for a resident, identified as R701, who was observed in their room with privacy cubicle curtains that had several round brown stains. The resident, who has a medical history of Major Depressive Disorder, Asthma, Respiratory Failure, and Muscle Weakness, expressed dissatisfaction with the cleanliness of the curtains, stating that they had informed the housekeeping staff about the issue. The resident's cognitive status was assessed as intact, with a BIMS score of 15. During an interview, the Housekeeping Supervisor confirmed that the curtains are cleaned once a month and acknowledged the expectation for them to be clean. The Nursing Home Administrator also affirmed the residents' right to a clean, homelike environment, as outlined in the facility's Resident Rights policy implemented in 2017.
Failure to Update PASARR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to update a Preadmission Screening and Resident Review (PASARR) for a resident diagnosed with Anxiety and Schizophrenia. The initial PASARR Level I screening indicated the need for a comprehensive Level II OBRA evaluation, but the resident was admitted under a hospital exempted discharge, which allowed for a temporary exemption from the Level II evaluation. However, the resident remained in the facility for more than 30 days, necessitating an updated PASARR screening, which was not completed in a timely manner. On April 3, 2024, it was discovered that the required updated PASARR screening had not been conducted. The social worker responsible for the resident was no longer with the company, and the new social worker indicated they would redo the PASARR themselves. The facility's policy mandates that PASARR Level I screenings be completed annually and with any significant change of status, and that any changes identified via the screen be reported to the state mental health or intellectual disability authority promptly. This policy was not followed in the case of this resident.
Failure to Change and Date PICC Line Dressing
Penalty
Summary
The facility failed to change and date a peripherally inserted central catheter (PICC) line dressing for a resident. The resident was observed with a lifting and undated PICC line dressing, and stated that it had not been changed since being placed in the hospital. The Licensed Practical Nurse (LPN) acknowledged the presence of the PICC line and intended to call the nurse practitioner for an order to remove it. The Director of Nursing (DON) confirmed that the resident returned from the hospital with the PICC line and antibiotics, and an order should have been entered to change the dressing every seven days per policy. The facility's policy mandates regular dressing changes to prevent catheter-related infections.
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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