Citations in Michigan
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Michigan.
Statistics for Michigan (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Michigan
Surveyors found that food service equipment and kitchen areas were not effectively cleaned or maintained, with persistent ice buildup, soiled sinks and vents, lime scale, food debris, and grease accumulation observed during multiple inspections. These unsanitary conditions affected 99 residents.
The facility did not follow its own abuse and neglect policies for two residents who reported rough or rude treatment by staff and a roommate. In both cases, the administrator did not conduct a thorough investigation or report the allegations to the state agency, and documentation was incomplete, failing to meet the facility's written protocols.
The facility did not report allegations of abuse involving two residents to the State Agency, despite being aware of incidents such as verbal altercations, staff rudeness, and rough handling during care. The administrator determined these incidents were not reportable and only minimal internal documentation and follow-up were completed, with no thorough investigation or external reporting.
Two residents reported incidents involving staff rudeness, rough handling, and verbal altercations, but the facility failed to conduct thorough investigations or maintain adequate documentation. The administrator determined these incidents did not meet abuse criteria and did not report them, resulting in insufficient follow-up and lack of comprehensive inquiry.
An LPN documented the administration of medications for a resident with multiple health conditions before the medications were actually given. The resident initially declined the medications, which were then labeled and stored in the medication cart. The LPN left the cart unlocked and unattended while preparing another resident's medication, and later administered the medications to the resident. The MAR showed the medications as given before actual administration, contrary to facility policy and professional standards.
A resident with neuropathy and other chronic conditions experienced unnecessary pain when staff failed to continue administering Neurontin as ordered by the provider. The medication, which had been effective in managing the resident's pain, was stopped without family notification, and there was a delay of several days before the provider's order to resume the medication was implemented.
A deficiency was cited when a resident’s drug regimen included unnecessary medications, either lacking clinical indication, being excessive in duration, or duplicative, without proper documentation to justify their use.
An LPN prepared a resident's medication in advance, placed it in a labeled cup, and stored it in an unlocked medication cart after the resident declined to take it immediately. The LPN then left the cart unattended and unlocked while assisting another resident, contrary to professional standards requiring medication carts to be locked and medications not to be pre-poured and stored for later use.
The facility did not ensure proper disposal of garbage, medical supplies, and yard debris, resulting in an open dumpster with exposed waste, litter, and flies in the surrounding area. Interviews revealed unclear staff responsibility for cleaning the area and the absence of a facility policy for dumpster cleanliness, despite expectations for the area to be kept clean.
A resident with significant physical limitations and upper extremity contractures was unable to access a specialty call light, which was not within effective reach, resulting in unmet care needs. The LPN assigned to the resident was initially unaware of how the call light should be used and only corrected its placement after being prompted. The facility's policy required call lights to be within reach, but this was not followed.
Failure to Maintain Clean and Sanitary Food Service Equipment and Environment
Penalty
Summary
Surveyors observed multiple failures in the facility's food service area regarding the cleaning and maintenance of equipment and surfaces. During initial and follow-up tours, the main freezer was found to have ice accumulation on the floor, and the walk-in cooler had food debris on the floor. The dishwasher exhibited lime scale and red deposits both inside and outside, with the surrounding floor also visibly soiled. Several hand sinks and faucets throughout the kitchen were stained and covered with lime deposits, and the toaster on the tray line had visible breadcrumbs on all sides. Oven racks were soiled with layers of burnt residue, and old grease and dust were present on top of the oven. Dust and cobwebs were noted on the sprinkler system above the stove, and the vent hood above the stove was covered with old grease. Additionally, five air vents in the kitchen ceiling and the surrounding ceiling tiles were observed to be soiled. These deficiencies were present during both the initial and follow-up inspections, indicating a lack of effective cleaning and maintenance practices. The issues affected the food service environment for 99 residents, as the unsanitary conditions persisted over multiple days and were not addressed between surveyor visits.
Failure to Implement Abuse and Neglect Policies and Procedures
Penalty
Summary
The facility failed to implement its own written policies and procedures for abuse and neglect prevention for two residents. One resident reported waiting two hours for assistance, after which a staff member entered her room, acted disgusted, and provided care in a rough manner, causing the resident pain and distress. Documentation showed that the incident was not thoroughly investigated, as required by facility policy. There was no evidence of interviews with the resident or staff, nor was the incident reported to the state agency, despite the policy stating that any suspicion or allegation of abuse warrants immediate investigation and reporting. Another resident, with moderate cognitive impairment and multiple medical diagnoses, reported that a staff member was rude to her and also described a verbal altercation with a roommate that made her feel unsafe. The facility's documentation of these incidents was minimal, with only brief notes indicating that the resident was moved or that the staff member received verbal education. There was no evidence of a comprehensive investigation, interviews with involved parties, or reporting to the state agency as outlined in the facility's abuse and neglect protocol. In both cases, the administrator determined that the incidents did not meet the criteria for abuse and therefore did not initiate a full investigation or report the allegations. The facility's actions did not align with its own policies, which require thorough investigation and timely reporting of all allegations or suspicions of abuse, neglect, or exploitation. The lack of proper documentation and follow-up demonstrates a failure to protect residents and ensure compliance with regulatory requirements.
Failure to Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency for two residents, despite being aware of the incidents. One resident, who had Huntington’s Disease and moderate cognitive impairment, reported that a staff member was rude to her and also described a verbal altercation with a roommate, expressing that she did not feel safe. These concerns were documented in facility grievance forms, and immediate actions such as moving the roommate were taken. However, the Nursing Home Administrator, who served as the abuse coordinator, determined that these incidents did not meet the criteria for abuse and did not report them to the state. Documentation provided for these events was minimal, with no thorough investigation records available beyond brief notes indicating the incidents were considered non-reportable and that no harm or distress was observed. Another resident reported waiting two hours for assistance and described being handled roughly by a staff member, which caused her pain. This concern was documented in a grievance form and a non-reportable allegation form, with a nursing assessment performed that found no new information or injury. The administrator and DON interviewed the resident, who stated she was in pain but could not identify the staff member involved. The administrator concluded that the incident was related to the resident’s underlying pain rather than staff mistreatment, and therefore did not report the allegation to the state agency. In both cases, the facility’s actions were limited to internal documentation and brief follow-up, without conducting or documenting thorough investigations or reporting the allegations to the appropriate authorities as required. The decision not to report was based on the administrator’s judgment that the incidents did not meet the threshold for abuse, despite the residents’ statements and the facility’s own documentation of their concerns.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of abuse for two residents out of four reviewed. One resident with Huntington’s Disease and moderate cognitive impairment reported that a staff member was rude to her, and also reported a verbal altercation with a roommate that made her feel unsafe. Documentation showed that the facility moved the roommate temporarily and provided verbal education to staff, but there was no evidence of a thorough investigation or interviews with the resident regarding the acceptability of the solutions. The facility administrator, who also served as the abuse coordinator, determined these incidents did not meet the criteria for abuse and did not report them to state agencies, nor did she maintain comprehensive investigation files beyond brief notes indicating no harm or distress. Another resident reported waiting two hours for assistance, after which a staff member allegedly acted disgusted, turned her roughly, and told her to stop yelling despite her pain. The concern was documented, and a nursing assessment was performed, but there was no documentation of a thorough investigation, interviews with the resident about the acceptability of the solution, or interviews with other staff or residents. The administrator concluded the incident was related to the resident’s pain and did not identify it as an abuse allegation, documenting only a brief summary on a non-reportable allegation form. In both cases, the facility did not conduct comprehensive investigations into the allegations of abuse or mistreatment, did not interview all relevant parties, and did not maintain adequate documentation of their investigative process. The administrator relied on her own judgment to determine that the incidents did not constitute abuse, resulting in a lack of proper reporting and investigation as required.
Failure to Follow Professional Standards for Medication Documentation
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow professional standards for medication documentation for a resident with multiple complex medical conditions, including aortic valve stenosis, congestive heart failure, diabetes, and vascular dementia. During a medication pass, the LPN prepared the resident's medications and documented their administration in the Medication Administration Record (MAR) before the resident actually received them. The resident initially refused to take the medications until after using the bathroom, prompting the LPN to label the medication cup and store it in the medication cart. The LPN then left the medication cart unlocked and unattended while preparing another resident's medication, only returning to lock it a few minutes later. The resident eventually took the medication after notifying the LPN that she was ready. However, the MAR reflected that the medications had been administered at an earlier time, prior to actual administration. Facility policy and the Director of Nursing's expectations require that medication administration be documented only after the medication has been given to the resident. The LPN's actions did not align with these standards, resulting in inaccurate documentation of medication administration.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to follow provider orders for a resident with multiple diagnoses, including congestive heart failure, COPD, muscle weakness, and neuropathy. The resident had impaired mobility and was dependent on staff for most activities of daily living. The resident had been prescribed Neurontin 100 mg capsules for neuropathy pain, which was reported by the family to be effective in managing the resident's burning and pain. However, the medication was stopped without discussion with the family, and the resident's pain returned. The family brought the issue to the attention of staff after noticing the resident's increased pain. Review of the medication administration records and interviews revealed that the provider had ordered Neurontin 100 mg three times daily after a two-week evaluation period, and this order was documented as received by the facility. Despite this, the medication was not administered from the date the order was received until several days later. Staff were unable to explain how the order was missed during this period, resulting in the resident experiencing unnecessary pain due to the lapse in medication administration.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated, excessive in duration, or duplicative, without adequate justification documented in the medical record.
Medication Security and Storage Deficiency
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) prepared a resident's medication by placing multiple prescribed drugs into a medication cup and labeling it with the resident's name. The LPN placed the cup in the top drawer of the medication cart after the resident declined to take the medication immediately, stating she wanted to use the bathroom first. The LPN then left the medication cart unlocked and unattended while preparing and administering medication to another resident. The cart remained unlocked and unattended for several minutes before the LPN returned and locked it. The resident involved had a complex medical history, including aortic valve stenosis, muscle weakness, dysphagia, congestive heart failure, diabetes, and other chronic conditions. The Director of Nursing (DON) confirmed that professional practice requires medication carts to be locked when not in use or not under direct supervision by a licensed nurse, and that medications should not be pre-poured and stored in the cart for later administration. The observed actions did not comply with professional standards for medication security and storage.
Failure to Maintain Cleanliness and Proper Waste Disposal in Dumpster Area
Penalty
Summary
The facility failed to properly dispose of garbage, medical supplies, and yard debris, resulting in unsanitary conditions in the dumpster and surrounding area. Observations revealed an open dumpster lid exposing boxes, loose paper, and tree branches, as well as a wheelbarrow filled with additional debris. The area around the dumpster and compressor was littered with leaves, paper, Styrofoam cups, plastic water bottles, medical gloves, yellow face masks, broken tree branches, cigarette butts, and flies swarming the dumpsters. No staff were present in the area during the observations. Interviews with facility staff indicated a lack of clear responsibility for maintaining cleanliness in the dumpster area. The Director of Maintenance stated that the staff member previously assigned to clean the area had been terminated, and that he was now responsible for cleaning it. The Nursing Home Administrator confirmed that the expectation was for the area to be kept clean but acknowledged that there was no facility policy addressing dumpster or compressor area cleanliness. The Director of Maintenance's job description included responsibility for groundskeeping and overall facility appearance.
Failure to Ensure Accessible Call Light for Resident with Physical Limitations
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including multiple sclerosis, upper extremity contractures, and impaired mobility, was found unable to access their specialty call light. The call light, designed to be activated using the resident's shoulder or the back of the head due to their inability to use their hands, was observed pinned to the bed covers on the right side of the bed, out of effective reach. The resident reported attempting to get staff attention for approximately half an hour without success, resulting in unmet care needs such as oral care and assistance with getting out of bed. During the observation, the resident demonstrated that the call light could only be activated with the back of the head, and its placement did not allow for this use. Further interviews revealed that the assigned LPN was initially unaware of how the resident could use the call light and only realized after re-entering the room that it was a motion-activated device. The LPN repositioned the call light under the resident's head, confirming that the previous placement was not accessible. The resident's care plan documented extensive assistance needs and encouraged participation in ADLs, but the failure to ensure the call light was within reach directly impacted the resident's ability to request assistance. The facility's policy required call lights to be within reach of residents, but this was not followed in this instance.
Some of the Latest Corrective Actions taken by Facilities in Michigan
- Educated nursing staff on assessment, physician notification, order implementation, and documentation (J - F0684 - MI)
Failure to Assess, Monitor, and Escalate Care for Residents with Changes in Condition
Penalty
Summary
The facility failed to adequately assess and monitor residents experiencing changes in condition, did not notify physicians of continued decline, and did not transfer residents to higher levels of care in a timely manner. For four residents reviewed, these failures resulted in significant negative outcomes, including two deaths, one resident requiring intubation after hospital transfer, and another developing sepsis leading to shock. The surveyors found that physician-ordered interventions were not implemented, abnormal vital signs and lab results were not acted upon, and documentation and communication among staff and providers were lacking. One resident with a history of cardiac arrest and atrial fibrillation had physician orders for Cardizem and increased free water flushes that were never administered or transcribed. This resident exhibited persistent tachycardia and hypoxia over several days, with no follow-up or escalation of care until they were transferred to the hospital in respiratory distress and subsequently intubated. Another resident with end-stage renal disease and chronic anemia had a critically low hemoglobin level, but despite the facility's awareness and the resident's history of requiring hospital evaluation for low hemoglobin, there was a lack of timely notification and transfer. The resident ultimately expired in the hospital with a hemoglobin of 3.2, and documentation did not reflect any refusal of hospital transfer. A third resident, who was alert and oriented, requested to be sent to the hospital due to shortness of breath and refused dialysis, but there was no evidence of provider follow-up or reassessment. Orders for medication were not documented as given, and the resident was later found unresponsive and pronounced dead. The fourth resident, admitted with sepsis and toxic encephalopathy, had elevated heart rate and declining oxygen saturation, but vital signs were not consistently documented, and there was a lack of provider progress notes. The resident was eventually transferred to the hospital and diagnosed with septic shock. Facility policy required notification of significant changes, but this was not consistently followed, and documentation was incomplete or missing.
Removal Plan
- Assess current residents for a change in condition by reviewing labs and vital signs.
- Educate nursing staff on assessment, notifying the physician, implementing orders, and documentation.
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