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
Three residents were not properly assessed or supervised for hot liquid safety, with one cognitively impaired individual suffering second-degree burns after spilling hot coffee served without a lid. Two other residents did not have up-to-date or completed hot liquid safety assessments, despite facility policy requiring regular evaluation and use of protective lids.
A resident with multiple sclerosis and limited mobility developed a worsening stage 3 pressure injury on the right heel due to staff failing to implement physician-ordered and care plan interventions, such as heel offloading and use of pressure-reducing devices. Despite clear orders and recommendations, the resident was observed without appropriate support surfaces or devices, and documentation showed the wound increased in size. The care plan and Kardex lacked necessary interventions, and a pressure-eliminating boot ordered by a consultant was not provided to the resident.
Two residents did not receive medications as ordered: one missed multiple doses of a dementia medication due to unavailability and lack of physician notification, while another received blood pressure medication outside of prescribed parameters on several occasions. The DON could not explain these failures, which did not meet professional standards.
Prescription medications were found unsecured in unlocked treatment and medication carts, and were left unattended at the bedside or on over-bed tables for multiple residents. Facility staff did not consistently follow policy requiring medications to be stored in locked compartments and under direct observation during administration.
Several residents requiring Enhanced Barrier Precautions due to conditions such as indwelling catheters, chronic wounds, and feeding tubes did not have appropriate signage or PPE available in their rooms, as observed by surveyors. Additionally, a nurse was seen administering a medication that had fallen onto the medication cart, placing it back into a cup with other medications before giving it to a resident, in violation of infection control protocols.
A resident with left-sided paralysis and moderate cognitive impairment was found in bed with the call light out of reach. The resident reported this occurred multiple times daily, and a staff member confirmed the call light was not accessible, contrary to facility policy requiring staff to ensure call light accessibility.
A resident with a history of TIA and cerebral infarction reported new stroke-like symptoms, including left-sided weakness and inability to grasp with the left hand. Despite these symptoms and family concerns, staff did not provide ongoing assessment, follow recommended monitoring, or send the resident for further evaluation. The resident missed two neurology appointments before being sent to the hospital, where imaging revealed a new chronic infarct. The facility lacked a stroke protocol and did not ensure timely intervention or follow-up.
The facility did not follow required procedures for timely reporting of an alleged abuse incident involving two cognitively impaired residents. After one resident accused a staff member of attempted rape during care, the incident was not reported to the State Agency within the mandated two-hour timeframe, despite facility policy requiring immediate reporting.
Two residents with end-stage renal disease did not receive proper medication management, accurate documentation, or adherence to physician orders regarding dialysis schedules and weight monitoring. One resident missed multiple doses of a prescribed medication, had altered dialysis days without physician notification, and experienced significant weight loss without intervention or dietician oversight. Another resident missed a dialysis session due to missing equipment, with no documentation or physician notification. Required assessments and communication forms were also missing.
Two residents requiring dialysis did not have proper documentation of dialysis communication, physician notification, or weights when their dialysis schedules were altered or missed. One resident was not sent with required equipment, resulting in an incomplete dialysis session, and staff could not explain or justify changes to the dialysis schedule.
Failure to Assess and Supervise Residents with Hot Beverages Results in Burn Injury
Penalty
Summary
The facility failed to adequately monitor and assess three residents for safety with hot liquid beverages, resulting in incomplete safety assessments for two residents and physical harm to another. One resident with severe cognitive impairment and a history of Alzheimer's disease and vascular dementia was served hot coffee from a Keurig machine in the activity room without a lid or ice, contrary to dietary instructions. The staff member prepared the coffee, placed it on the table, and then turned away, during which time the resident spilled the coffee onto himself, sustaining second-degree burns to his abdomen, left arm, and left thigh. The temperature of the coffee was later found to be between 177.6 and 178.7 degrees Fahrenheit, exceeding the facility's policy range of 140 to 160 degrees Fahrenheit for serving hot beverages. Further review revealed that another resident with mild cognitive impairment had not received a hot liquid safety assessment since a previous date, despite using the Keurig machine during activities. A third resident, who was cognitively intact, had no completed hot liquid assessment since admission or readmission. The facility's policy required all residents to be assessed for their ability to handle hot beverages on admission, quarterly, annually, and upon significant change in status, and mandated the use of hard plastic lids on cups. These requirements were not consistently followed, leading to the cited deficiencies.
Failure to Implement Pressure Injury Interventions Resulting in Worsening Wound
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis, who was non-ambulatory and at risk for pressure injuries, developed a stage 3 pressure injury on the right heel while residing in the facility. Despite physician orders and care plan interventions to float the resident's heels while in bed and to offload pressure while in a wheelchair, staff failed to implement these interventions. Observations revealed the resident was repeatedly found with both feet placed directly on the floor without any pressure-reducing device while in a wheelchair, and with heels resting directly on the mattress while in bed. The resident confirmed that staff had not provided pressure-reducing boots or elevated her heels as required. Review of the medical record showed that the pressure injury was first identified as stage 3 and subsequently worsened in size over time. Documentation indicated that the wound was not healing, with saturated dressings, increased wound size, and the presence of slough and odor. The care plan and Kardex did not include specific interventions to reduce pressure on the heel while the resident was in the wheelchair, and staff were not directed to implement pressure-relieving measures. A consultant physician had recommended and ordered a pressure-eliminating boot, but this order was not implemented, and the boot remained unused in the DON's office. Interviews with the DON and staff confirmed a lack of awareness and implementation of the required interventions. The DON admitted that the resident should have had pressure-reducing boots or similar devices and acknowledged that the care plan and Kardex were incomplete regarding pressure injury interventions. Facility policies and national guidelines require elevation of heels and use of appropriate devices to prevent and treat pressure injuries, but these standards were not followed, resulting in the worsening of the resident's pressure injury.
Failure to Provide and Administer Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that medications were available and administered according to physician orders for two residents. One resident with Parkinson's Disease and Dementia had a physician order for Namenda 10 mg twice daily for Dementia. Documentation showed that the medication was not available from the evening of August 12th until the morning of August 22nd, resulting in the resident missing 19 doses. There was no documentation that the physician was notified about the unavailability of the medication during this period. Another resident with hypertensive heart disease, heart failure, chronic kidney disease stage 3, and aortic valve stenosis had a physician order for Hydralazine 25 mg every 12 hours, to be held if blood pressure was less than 140/90. Despite nursing staff documenting blood pressures prior to administration, the medication was given outside the ordered parameters 16 times. During an interview, the Director of Nursing was unable to explain the medication unavailability and the administration of medication outside physician parameters, acknowledging that these actions did not meet professional standards.
Failure to Secure and Supervise Prescription Medications
Penalty
Summary
Surveyors observed that the facility failed to properly secure prescription medications in multiple locations, including two of four treatment carts and one of four medication carts. On several occasions, treatment carts on different halls were found unlocked and contained prescription ointments, bandages, scissors, and other prescription medications. Additionally, a medication cart was observed unlocked and unattended, and prescription medications were left unattended on top of a medication cart. For three residents reviewed, medications were found left at the bedside or on over-bed tables without a nurse present. One resident and their family member confirmed that medications were sometimes left on the bedside table for the resident to take later. Another resident was observed with a cup of pills on the over-bed table while resting, with no nurse present. A third resident and their partner reported that nurses would leave medications at the bedside from time to time, and the partner would ensure the resident took the pills. Facility policy requires all drugs and biologicals to be stored in locked compartments and under direct observation during medication passes, which was not followed in these instances.
Failure to Implement Enhanced Barrier Precautions and Proper Medication Administration
Penalty
Summary
The facility failed to implement and maintain proper infection control practices for residents requiring Enhanced Barrier Precautions (EBP) and during medication administration. Multiple residents with conditions such as neuromuscular dysfunction of the bladder, indwelling catheters, chronic wounds, and feeding tubes were identified as needing EBP according to their care plans. However, observations revealed that there was no signage indicating EBP requirements on their room doors, nor was personal protective equipment (PPE) available for staff to use during close contact care. These lapses were confirmed by the Director of Nursing and a Registered Nurse, both certified Infection Control Practitioners, who acknowledged that EBP had not been implemented as required and that physician orders or care plans had not been reviewed during their audit. Additionally, during medication administration, a registered nurse was observed preparing medications when a pill fell onto the medication cart. The nurse retrieved the pill using the medication card and placed it into a medication cup with other medications before administering them to a resident. This practice did not adhere to proper infection control protocols for medication administration, as the pill was potentially contaminated before being given to the resident.
Call Light Accessibility Not Maintained for Dependent Resident
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident with significant physical and cognitive impairments. The resident, who had left-sided paralysis following a stroke and moderate cognitive impairment, was observed in bed with the touch pad call light out of reach. The resident reported that the call light was out of reach two to three times a day, causing frustration. A staff member confirmed during the observation that the call light was not accessible to the resident. Review of facility policy indicated that staff are educated to ensure resident access to call lights, but this was not followed in this instance.
Failure to Provide Timely Assessment and Intervention for Suspected Stroke
Penalty
Summary
A deficiency occurred when the facility failed to provide timely and ongoing assessment and intervention for a resident who experienced a change in condition suggestive of a stroke. The resident, with a history of transient ischemic attack (TIA), cerebral infarction, encephalopathy, and hypertension, reported symptoms including tingling in the left arm and inability to grasp with the left hand. The nurse documented these symptoms and notified the nurse practitioner (NP), who assessed the resident but did not identify significant changes or initiate further evaluation beyond recommending increased blood pressure monitoring. There was no evidence that the recommended monitoring was implemented or that the resident was reassessed following the initial change in condition. The resident's family reported concerns to the facility about the resident experiencing stroke-like symptoms and missing scheduled neurology appointments. Despite these reports and the resident's new onset of left-sided weakness, the facility did not send the resident for further evaluation or to the hospital, as confirmed by the Director of Nursing (DON), who stated that the expectation was to send residents out immediately for new stroke symptoms. The DON also confirmed that the facility lacked a stroke protocol or policy and that no follow-up was conducted on the resident's change in condition. The therapy department identified a significant change in the resident's functional ability the day after the initial symptoms, but there was still no reassessment or intervention documented. The resident ultimately missed two neurology appointments before being seen by a neurologist, who then sent the resident to the hospital for evaluation of a suspected stroke. Hospital records indicated a new chronic lacunar infarct on imaging. The facility failed to provide appropriate and timely care in response to the resident's change in condition, as well as to ensure attendance at necessary medical appointments.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its policies and procedures for timely reporting of a reasonable suspicion of a crime, as required by section 1150B of the Act. Two residents with cognitive impairments, one with Alzheimer's disease and severe impairment and another with unspecified dementia and moderate impairment, were involved in an incident where one resident was observed grabbing the other's foot. During care, the resident accused a staff member of attempted rape, prompting immediate cessation of care. Both residents were assessed and found to have no injuries. Law enforcement responded but could not obtain statements due to the residents' inability to recall the event. The incident occurred at 11:00 AM and was discovered at 12:30 PM, but was not reported to the State Agency until 5:02 PM, exceeding the required two-hour reporting window. The Nursing Home Administrator confirmed that abuse allegations must be reported immediately, but this protocol was not followed in this case.
Failure in Medication Management, Documentation, and Adherence to Physician Orders for Dialysis Residents
Penalty
Summary
The facility failed to ensure proper medication management, accurate documentation, recognition of changes in condition, and adherence to physician orders for two residents with end-stage renal disease dependent on dialysis. For one resident, there was an active physician order for transport to dialysis on specific days and notification of the physician for missed appointments, as well as weight monitoring. The resident's dialysis schedule was altered without justification or documentation, and there was no evidence of physician notification or weight documentation for missed or changed dialysis sessions. Additionally, the resident did not receive the prescribed Sevelamer HCl for chronic kidney disease, with multiple doses marked as administered on the MAR despite the medication not being available in-house. Nurses' notes indicated the medication was not available, and the DON confirmed the MAR entries were inaccurate and that the medication was never present during the resident's admission. The same resident experienced poor oral intake, with documentation showing less than 75% meal consumption at every meal and no evidence that snacks or alternatives were offered. There was only one recorded weight during the admission, reflecting a significant weight loss, with no documentation addressing the cause or interventions. The resident did not receive a Registered Dietician consultation or progress notes, and required social services assessments were not completed until after discharge. The social worker reported being unable to complete assessments due to the resident's lethargy but did not notify nursing staff, and there was no documentation of assessment attempts. Family members reported concerns about the resident's eating difficulties and mood changes, which were not addressed by the facility. For the second resident, there was also a failure to adhere to the prescribed dialysis schedule and to notify the physician or document weights when dialysis was missed or altered. The resident missed a dialysis session due to the facility not sending the required Hoyer sling, and there was no documentation of physician notification or weight monitoring. Dialysis communication forms were missing from the medical record, and staff could not explain the changes to the dialysis schedule. These deficiencies demonstrate a lack of compliance with physician orders, medication management, documentation, and recognition of changes in condition for residents requiring complex care.
Failure to Maintain Dialysis Coordination and Documentation
Penalty
Summary
The facility failed to maintain required dialysis coordination and communication documentation for two residents who required dialysis services. Both residents had physician orders specifying dialysis schedules and instructions to notify the physician of missed appointments and to obtain weights. However, the medical records for both residents lacked dialysis communication forms, documentation of physician notification, and records of weights when dialysis appointments were missed or altered. Staff were unable to explain or justify changes to the dialysis schedules, and there was no documentation to support why the residents' dialysis days were changed from the ordered schedule, despite the dialysis center being open on the originally scheduled days. One resident was not sent with the necessary Hoyer sling for transfer at the dialysis center, resulting in an incomplete dialysis session, and there was no documentation that the physician was notified or that a weight was obtained. The other resident's dialysis days were altered without explanation or documentation, and again, there was no evidence of physician notification or weight documentation. The Director of Nursing acknowledged that dialysis communication forms could not be located and that the facility was working to improve the process.
Some of the Latest Corrective Actions taken by Facilities in Michigan
- Educated staff on the residents’ sexual-consent capacity and safe-sex practices to guide appropriate supervision and protect resident rights (J - F0600 - MI)
- Revised the residents’ care plans to document consent status and outline interventions that ensure privacy, safety, and dignity for all future intimate interactions (J - F0600 - MI)
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when nursing staff failed to initiate cardiopulmonary resuscitation (CPR) for a resident who was found unresponsive, despite the resident having a documented full code status. The assigned agency RN did not perform CPR upon discovering the resident unresponsive and without vital signs, and instead pronounced the resident deceased. The nurse stated she was informed the resident was on hospice and did not recall the code status, leading to no resuscitative efforts being made. Other staff, including CNAs, were aware of the resident's full code status and expected that CPR should have been started, but no action was taken to initiate a code or call emergency services. The resident involved had a history of hereditary ataxias, dysphagia following cerebral infarction, and Parkinson's disease, and was admitted to hospice services with a clear advance directive indicating full cardiopulmonary resuscitation. Despite this, the care plan did not document the code status or advance directives, and the nurse relied on verbal information about hospice status rather than verifying the resident's documented wishes. The nurse did not check the medical record or care plan for code status before deciding not to initiate CPR. Interviews with staff revealed a lack of clarity and communication regarding the resident's code status, with some staff assuming hospice status equated to a do-not-resuscitate (DNR) order. The facility's policies required CPR to be initiated for full code residents unless a DNR order was present and documented. The failure to follow these policies and verify the resident's code status resulted in the resident not receiving basic life support prior to death.
Removal Plan
- All resident charts were audited to confirm code status based on Resident/POA wishes.
- Facility licensed staff were provided with in-service education. Education included ensuring CPR was initiated for residents identified as full codes, a resident on hospice does not mean DNR code status, location of code status preference in resident records, and review of facility cardiac arrest emergency management policy.
- Agency licensed staff were provided with in-service education. Education included ensuring CPR was initiated for residents identified as full codes, a resident on hospice does not mean DNR code status, location of code status preference in resident records, and review of facility cardiac arrest emergency management policy.
- The Director of Nursing will ensure that all staff received in-service education and completed education was documented prior to working their next assigned shift.
- The Director of Nursing/Designee will monitor all booked shifts for Agency licensed staff for completion of assigned required in-service education and completed education was documented prior to working the scheduled shift.
- The medical director was notified.
- The Director of Nursing held mock CPR drills with nursing staff on each shift.
- Director of Nursing will conduct mock CPR drills monthly on each shift.
- Information from the drills will be reviewed for recommendations at QA&A committee meetings monthly.
- An Ad-Hoc QAPI meeting was held to review findings and action plan.
Failure to Prevent Sexual Abuse of Cognitively Impaired Residents
Penalty
Summary
Facility staff failed to appropriately assess, supervise, and ensure an environment free of sexual abuse for two legally incapacitated residents with severely impaired cognition. Both residents, one with a BIMS score of 2 and the other with a BIMS score of 3, were found unsupervised and involved in a sexual encounter in one resident's bed, both unclothed from the waist down. Staff discovered the incident during the night shift, and it was noted that one resident had a history of seeking male attention and inviting male residents into her room, while the other had a history of sexually inappropriate behavior and aggression. Medical records and care plans for both residents documented severe cognitive impairment, legal guardianship, and the need for supervision and redirection due to behavioral symptoms and impaired judgment. Despite these documented vulnerabilities, the facility permitted the residents to engage in sexual activity without adequate supervision or intervention. Staff, including the Administrator and Nurse, acknowledged that the resident involved was unable to recall the incident, understand the risks or consequences of sexual encounters, or provide meaningful consent due to her dementia and cognitive deficits. Interviews with the social worker, legal guardian, and staff confirmed that the resident could not process or remember the events and did not have the capacity to understand or consent to sexual activity. The facility's own policy required both decision-making capacity and capacity for sexual consent evaluations, yet the resident had previously been declared mentally incapacitated and unable to make informed decisions. Despite this, a physician's assessment after the incident concluded that the resident had capacity to consent, a determination that was questioned by staff and the legal guardian. The lack of supervision and failure to intervene allowed the incident to occur, resulting in a situation where two severely cognitively impaired, legally incapacitated residents were left vulnerable to sexual abuse.
Removal Plan
- Residents were immediately separated.
- Resident R909 was escorted to the nursing station for supervision.
- Resident R910 was placed on one-to-one supervision for safety and continued monitoring.
- Administrator was notified by the nurse.
- Physicians, legal guardians, and the ombudsman were notified.
- Police were called to the facility, arrived on site, and interviewed both residents.
- Pain and skin assessments were attempted on both residents.
- Physicians completed a Capacity for Sexual Consent/Intimacy Evaluation on both residents.
- Capacity results were shared with both residents and their legal guardians along with counsel on safe sex practices.
- Staff were educated on the capacity results.
- Care plans updated to reflect the determination that both residents were deemed cognitively able to consent to sex, their desire, and interventions to ensure privacy, safety and dignity.
- If either resident is likely to seek out other residents for non-exclusive sexual behavior, the facility's approach to limiting access to residents who are unable to consent includes providing staff education and increasing supervision as necessary.
Failure to Prevent Elopement and Inadequate Response to Alarms
Penalty
Summary
The facility failed to provide adequate monitoring and supervision to prevent elopement and respond appropriately to door and Wanderguard alarms for two residents identified as being at risk for elopement. One resident with severe cognitive impairment and a history of exit-seeking behavior was able to exit the facility through an employee entrance door after following a CNA who was leaving for break. The resident was found outside by another resident approximately ten minutes later, attempting to re-enter the building. Staff did not respond to the door alarm in a timely manner, and there was confusion among staff regarding the source and significance of the alarms, with some staff assuming the alarms were related to shift change and not investigating further. The resident who eloped had a documented history of wandering, elopement risk, and severe dementia, with care plans and assessments indicating the need for close supervision and the use of a Wanderguard device. Despite these interventions, the resident was able to leave the building unsupervised. Staff interviews revealed a lack of familiarity with alarm systems, Wanderguard functionality, and facility protocols, particularly among agency staff and new hires. There was also a lack of clear documentation and communication regarding the checking and maintenance of Wanderguard devices for another resident at risk for elopement, with no evidence that required checks were being performed or documented. Facility policies and orientation materials did not provide sufficient guidance on responding to alarms, identifying alarm sources, or the use of Wanderguard devices. Agency staff were not consistently oriented to these procedures, and there was no verification that required orientation or competency checks had been completed. The combination of inadequate staff response, insufficient training, and lack of documentation contributed to the failure to prevent the elopement and ensure the safety of residents at risk.
Removal Plan
- Resident #101 was placed on 1:1 supervision until further interventions could be implemented. Law Enforcement, physician and Director of Nursing notified. The Administrator notified the brother of the incident.
- The EVS (environmental services) Director assessed the facility doors for proper function of the alarm system.
- The Administrator reviewed the elopement binder.
- The Elopement and Wandering Policy was reviewed by the facility Administrator.
- Assessments were completed on the resident to ensure the resident did not experience any adverse effects of the elopement, including skin assessment, pain assessment and vital signs were obtained.
- Care Plan was updated with proper interventions to reduce future risk of elopement.
- The facility audited residents who were determined to be at risk for elopement. The Facility completed an elopement risk observation, reviewed and/or updated the elopement care plan and ensured appropriate interventions.
- Resident #104's orders were put in place to ensure Wanderguard functionality would be checked.
- Agency LPN's and staff Cena's were educated by the DON, Maintenance and Administrator on the facility's policy on elopement and wandering. An elopement drill was completed.
- Education of elopement and wandering policy was initiated; any staff member who did not receive education will receive education prior to the start of their next shift.
- All Staff have been educated.
- Agency Staff have received the education prior to working their next shift.
- Agency staff education will include an in-person orientation with new agency staff that will include how to determine where the alarm is coming from, how the doors function, Wanderguard usage, door codes, and expectations for responding to a door alarm.
Explore Popular Searches
