Alamo Nursing Home Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Kalamazoo, Michigan.
- Location
- 8290 W C Ave, Kalamazoo, Michigan 49009
- CMS Provider Number
- 235311
- Inspections on file
- 22
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Alamo Nursing Home Inc during CMS and state inspections, most recent first.
A resident admitted with intact skin, high risk for pressure injury, and total dependence for care was care planned for pressure ulcer prevention but did not consistently receive required assessments, skin checks, or q2h repositioning. Hospital records documented sacral/coccyx and heel pressure injuries that were not recorded on facility re‑admission assessments, and facility skin documentation initially described new gluteal abrasions later recognized as part of an unstageable coccyx pressure ulcer. Wound care orders for the coccyx and other pressure injuries were delayed or incompletely documented, with multiple missing entries on the treatment record. Staff interviews confirmed frequent missed showers, skin assessments, repositioning, and treatments due to staffing issues, while family reported never seeing staff reposition the resident and repeatedly raising concerns that were not effectively addressed, resulting in the development and worsening of multiple pressure ulcers.
Two residents experienced significant medication errors when ordered drugs were not administered in accordance with physician orders and facility policy. A resident with diabetes had insulin doses increased and then received short‑acting insulin late and only 2.5 hours apart, without the LPN confirming pre‑meal blood glucose or food intake, despite a prior severe hypoglycemic episode that was not brought to a provider for assessment or insulin adjustment. Another resident with epilepsy missed multiple doses of Keppra and valproic acid over several days due to refusal and dysphagia, with staff documenting lethargy, poor responsiveness, inability to swallow, and seizure activity, yet there was no documented provider notification about the repeated missed antiepileptic doses until an LPN, alerted by a CNA, assessed swallowing difficulty and arranged hospital transfer. These actions and omissions conflicted with the facility’s medication administration and change‑in‑condition policies, which required timely administration, documentation, and provider notification for missed doses and acute changes.
Multiple residents who required assistance with ADLs, including those with TBI, MS, dementia, chronic pain, and mobility deficits, did not consistently receive scheduled showers or bed baths, and refusals were not reliably documented. One resident was admitted to the hospital soaked in urine with crusting around the eye and mouth, while a family member reported the resident was frequently disheveled, in soiled or double briefs, and often missed scheduled showers despite repeated complaints to staff and management. Staff, including LPNs, CNAs, and the shower aide, reported that short staffing, frequent reassignment of the shower aide to the floor, and an excessive number of scheduled showers led to missed ADL care. Documentation for several residents showed fewer showers than scheduled, inconsistencies between task records and shower sheets, and missing progress notes for recorded refusals, despite a stated process requiring re‑approach and nurse documentation of refusals.
A resident with paranoid schizophrenia, dementia, and cognitive communication deficit had a care plan addressing behavioral concerns and the need for behavioral health interventions, but required PASRR Level I and Level II evaluations were not completed on time. A prior Level II determination allowed continued NF residence with potential specialized MH/DD services and specified a due date for the next Level II, which was not met. The SSD reported not having the current Level II and was unsure if the OBRA evaluator had assessed the resident, and the NHA confirmed that while a Level I and Level II had been completed the previous year, there was no Level I documented for the current year, resulting in noncompliance with PASRR requirements.
Surveyors found that staff did not implement care plan interventions for three residents, including fall-prevention measures and eating assistance. One resident with multiple sclerosis, dementia, and a history of falls was repeatedly observed leaning off the side of the bed without the prescribed pillow, blanket, or wedge in place. Another resident at high risk for falls, with dementia and MS, had a care plan requiring a non-slip dycem pad at the side of the bed after a fall, but the dycem was never present and staff were unaware of the intervention despite it being listed on the Kardex. A third resident with type 2 DM and an ADL self-care deficit had a care plan and progress notes indicating she required assistance with eating, yet documentation frequently recorded her as independent or needing only setup, staff reported she typically ate alone in her room without help, and she was observed struggling to feed herself without staff assistance.
A resident with a history of renal stones and a ureteral stent continued to have an indwelling Foley catheter for months after a urology visit, despite written instructions that it was acceptable to remove the catheter and only replace it if voiding problems occurred. The resident repeatedly complained of leaking and pain, and nursing notes documented multiple episodes of catheter leakage, resistance on reinsertion, and the presence of a blood clot, with several unsuccessful attempts to replace the catheter before allowing the resident to void without it. The resident stated he had asked staff several times to reassess the need for the catheter and felt the facility did not act promptly. The UM, MD, and PA each reported they had not assessed whether the catheter was still necessary after the urology visit, and the UM acknowledged that the urology instructions supported removal but could not explain why it was not done.
A resident with a history of CVA, malnutrition, dysphagia, and PEG-dependent enteral nutrition was care planned as NPO for all nutrition, hydration, and meds, yet staff were observed repeatedly providing water orally using sponge-tipped swabs. CNAs reported giving the resident water whenever he asked, despite acknowledging he was NPO and on fluid restriction, and that lemon swabs were supposed to be used instead. A full cup and jugs of water were found at the bedside, and a physician note documented the presence of bedside water for this NPO resident. The unit manager stated the resident should not have received water due to inability to swallow and acknowledged that oral care instructions in the Kardex and care plan were unclear, contributing to care that was inconsistent with professional standards for enteral nutrition management.
The facility failed to maintain complete and accurate medical records for three residents, including multiple missing entries on Treatment Administration Records for wound care, G-tube checks, catheter care, use of pressure-relieving boots, pulse oximetry assessments, and oxygen concentrator checks. For one resident with muscle weakness and personal care needs, several ordered wound and device-related treatments in a given month lacked documentation of completion or refusal. Another resident with DM2, pneumonia, and pressure injuries had undocumented wound treatments and respiratory monitoring tasks on several days. A third resident with MS, dementia, and a history of falls had no weekly skin assessments documented over multiple weeks, despite staff interviews confirming that weekly skin assessments and UAD alerts were expected and that missed treatments or refusals should be documented in the record.
A resident with a history of pressure ulcers and high risk for skin breakdown experienced worsening wounds due to inadequate care, including lack of regular repositioning, improper incontinence management, inconsistent application of barrier cream, and failure to maintain infection control precautions. Staff were unaware of the resident's wound status, did not follow care instructions, and did not consistently check on the resident, resulting in significant deterioration of the resident's pressure ulcer.
A resident was not provided with prescribed hospital discharge medications upon admission due to a delay in confirming and activating medication orders in the facility's system. The LPN entered the orders, but a required second check and activation were not completed, resulting in the pharmacy not receiving the orders until the following day. This led to the resident missing multiple scheduled doses of essential medications and ultimately being readmitted to the hospital.
Staff did not follow physician orders for Enhanced Barrier Precautions (EBP) when providing care to a resident with a pressure ulcer and urinary catheter. During observed care activities, including incontinence and wound care, a CNA, an LPN, and a unit manager did not wear gowns as required. The resident's wound had worsened, and EBP requirements were not posted at the door, leading to inconsistent use of infection control measures.
The facility failed to maintain proper sanitation and food safety standards, affecting 84 residents. Observations included a slow-draining sink, uncovered utensils, and soiled equipment. Food items lacked proper labeling and dating, with some past their best-by dates. Opened food packages were not securely sealed, and storage practices were inadequate, increasing the risk of contamination and foodborne illness.
The facility failed to maintain a clean and safe environment, affecting 84 residents. Observations revealed issues such as corroded appliances, missing laminate, loose fixtures, and heavily soiled ventilation grills. Maintenance aides indicated the use of the TELS program for work orders, but no related entries were found. The facility's policies for maintenance and housekeeping were not adhered to, leading to significant deficiencies.
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet needs in areas such as incontinence care, pressure ulcer prevention, and respiratory care. A resident at high risk for pressure sores lacked a care plan addressing this risk, while another receiving hospice services did not have these services reflected in their care plan. Additionally, a resident with obstructive sleep apnea had a CPAP machine that was not properly maintained, despite documentation indicating it had been cleaned.
The facility failed to maintain appropriate food temperatures and quality, affecting residents' meal satisfaction and nutritional intake. Observations showed food items were below required temperatures, and residents reported dissatisfaction with cold and undercooked meals. The Dietary Manager acknowledged these issues, and a group meeting confirmed widespread resident concerns.
The facility failed to honor resident food preferences, impacting several residents. A resident received food items listed as dislikes, while another received inappropriate food textures. A third resident experienced significant weight loss due to smaller portions than requested. Other residents reported frequent meal substitutions without notice and missing items on meal trays. These issues highlight the facility's failure to adhere to policies accommodating residents' dietary needs.
The facility failed to ensure proper glove use during incontinence care and injection administration, and sanitary storage of respiratory equipment, affecting three residents. A resident with cognitive impairment received incontinence care with improper glove use, while another resident with a brain injury experienced similar issues. Additionally, a resident with sleep apnea had a soiled CPAP machine, and an LPN administered an injection without gloves or hand hygiene, compromising infection control standards.
The facility failed to maintain resident dignity and respect, as evidenced by incidents involving a resident with wet pants and unmet incontinence needs, another resident ignored during care, and a third resident dismissed when seeking pain relief. A group meeting revealed widespread dissatisfaction with staff treatment, including unfamiliarity with resident needs and inadequate attention during night shifts.
The facility failed to assess two residents for safe self-administration of medications. One resident was found with a medication cup left by a nurse, and another was unsure about a pill's identity. The DON confirmed no residents were assessed for self-administration, and staff should supervise medication intake.
A facility failed to investigate abuse allegations for two residents. One resident reported thumb injuries caused by a staff member, but no investigation was conducted. Another resident, known to be combative, was reportedly restrained by a CNA during care. Witnesses described the CNA's actions as abusive, but the facility's investigation was incomplete and concluded no abuse occurred.
The facility failed to provide written bed hold notices to two residents and their representatives during hospital transfers, as required by policy. One resident, who was cognitively intact, was transferred twice without receiving the notice, and another resident was transferred at his wife's request without documentation of the notice. Interviews confirmed the requirement to provide the notice, but the facility could not locate the necessary documentation.
An LPN failed to follow professional standards during medication administration by not wearing gloves or performing hand hygiene after administering an insulin injection to a resident. The LPN then entered another resident's room and handled a meal tray without performing hand hygiene. The LPN believed gloves and hand hygiene were unnecessary as there was no exposure to blood or body fluids, contrary to CDC guidelines.
Two residents in a LTC facility did not receive adequate ADL care. A resident with edema was observed without prescribed ted hose, despite documentation indicating they were applied. The LPN admitted to not verifying their application. Another resident, cognitively intact, reported not receiving a shower for weeks and lacked basic hygiene assistance, resulting in an unkempt appearance. The facility failed to meet these residents' ADL needs.
Two residents at high risk for pressure ulcers did not receive adequate preventative care. One resident, cognitively impaired and dependent on staff, was left in a broda chair for extended periods without repositioning or incontinence care, leading to wetness and potential skin damage. Another resident, severely impaired and dependent, was also left in a broda chair without repositioning or offloading pressure, and was found with a bulging incontinence brief and wet pants. The facility failed to implement necessary preventative measures, risking the development of avoidable pressure ulcers.
A facility failed to ensure safe transport and transfer practices for residents, leading to potential injury risks. A resident with a history of falls was transported in a wheelchair without foot pedals, and transfers were conducted without a gait belt. Another resident experienced a fall when a new CNA did not use a gait belt during a transfer. Staff interviews confirmed that gait belts should be used for all non-mechanical lift transfers, and foot pedals should be in place when pushing a wheelchair.
Two residents in a LTC facility were left in wet incontinence briefs for extended periods, with staff failing to provide timely care and adhere to infection control practices. One resident, who was cognitively impaired, was observed in a wet brief without being checked or changed, and proper hygiene was not followed during care. Another resident, severely impaired, was also left in a wet brief, with staff neglecting to provide care until a family member intervened. These deficiencies pose risks for skin breakdown and UTIs.
A facility failed to maintain and store CPAP equipment in a sanitary manner for a resident with obstructive sleep apnea, leading to potential respiratory risks. The resident's CPAP machine, hose, and mask were heavily soiled, and the water container was empty with residue. Despite orders for daily cleaning, the equipment was not maintained, and the resident's care plan did not reflect the use of a CPAP machine.
A facility failed to limit a resident's PRN psychotropic medication to 14 days, as required by policy, without a documented rationale from the physician. The resident, with diagnoses including PTSD and anxiety disorder, was receiving Xanax and Ativan. The physician's order for Xanax as needed did not include a 14-day limit or a stop date, and there was no documented rationale for extending the PRN order.
A resident with Alzheimer's who was known to resist care was physically restrained and verbally intimidated by a CNA during incontinence care, despite a care plan directing staff to use de-escalation and re-approach strategies. Other CNAs present objected to the treatment and reported it as abusive, but the accused CNA continued working until facility leadership intervened. The incident highlights a failure to follow the care plan and protect the resident from abuse.
A resident with kidney failure alleged being kicked by staff, resulting in cracked ribs and hospital admission. Despite being informed of the abuse allegation at 1:00 AM, the NHA delayed submitting the Facility Reported Incident until 10:39 AM, about 10 hours later, leading to a potential delay in investigation and further abuse.
A facility failed to provide adequate supervision for three residents at high risk for falls, resulting in repeated falls and injuries. One resident sustained cervical and rib fractures, another experienced multiple falls despite being monitored in common areas, and a third resident with dementia was left unsupervised, leading to several falls. Staffing issues and insufficient interventions contributed to these deficiencies.
The facility failed to provide sufficient staffing, resulting in multiple falls for residents at risk. A resident on the rehab hall experienced several falls due to inadequate supervision, suffering a significant injury. Another resident, who was restless and frequently attempted to get out of bed, also fell multiple times due to insufficient monitoring. The facility's reliance on agency nurses and reduction in staff numbers exacerbated the situation, making it difficult for staff to provide necessary care and supervision.
The facility failed to provide evening snacks consistently, leading to dissatisfaction among residents. Staff reported that snacks were primarily available for diabetic residents, and non-diabetic residents often had to rely on staff purchasing snacks externally. The Dietary Manager cited reduced evening kitchen staff as a contributing factor, and the Director of Nursing was unaware of the issue.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with chronic wounds or indwelling medical devices, leading to potential MDRO transmission. Observations revealed that CNAs did not wear gowns or gloves during high-contact activities, and there was confusion about PPE usage. Interviews indicated a misunderstanding of EBP requirements, as staff believed PPE was only necessary during wound care when wounds were uncovered.
A resident with osteomyelitis and pressure ulcers did not receive appropriate wound care due to a malfunctioning wound VAC and lack of staff training, leading to hospitalization with MRSA septicemia. The facility failed to follow prescribed wound care orders, and the DON was unaware of the issues, resulting in missed treatments and inadequate documentation.
A resident with a history of traumatic brain injury and cognitive deficits experienced multiple unwitnessed falls due to inadequate supervision at the LTC facility. Despite a care plan acknowledging the resident's fall risk, no interventions for supervision were implemented, leading to injuries and subsequent medical complications.
A resident with a feeding tube was found unresponsive and lying flat in bed, despite needing head elevation during feeding. The resident, who had a history of traumatic brain injury and other conditions, was transported to the hospital and pronounced dead. Interviews revealed that nursing staff failed to monitor the resident adequately, and there was no documentation of care during the critical hours leading to the incident.
A resident with pressure ulcers experienced a malfunction with her wound vac for several days without receiving alternative wound care, leading to hospitalization. Her family member submitted a grievance form regarding this issue and other care concerns, but the facility's administration reported not receiving it, indicating a failure in the grievance process.
A facility failed to follow physician orders for a diabetic resident, resulting in improper insulin administration and lack of physician notification for high blood sugar readings. Despite documentation indicating high blood sugar levels, the resident did not receive the prescribed insulin dosage, and there was no evidence that the physician was informed. The DON acknowledged the issue, but the facility could not provide documentation of physician notification.
A resident with pressure ulcers requiring a wound vac did not receive proper care due to the nursing staff's lack of competency in using the device. The wound vac malfunctioned for several days, and no wound care was provided, leading to the resident's hospitalization. Interviews revealed that the facility had not trained staff on wound vac use, and there was no documentation of missed treatments or physician notifications.
The facility failed to maintain a functional nurse call system, leading to delays in responding to residents' calls for assistance. Staff reported ongoing issues with broken or missing cell phones, weak internet connections, and the need to share phones, causing frustration and long wait times for residents.
The facility failed to provide sufficient staff, resulting in long call light wait times, residents being left wet/soiled for extended periods, missed showers/baths, late medications, and staff burnout. Residents reported significant delays in receiving care, and staff confirmed being overwhelmed due to low staffing levels.
The facility failed to conduct annual performance reviews for five CNAs who had been employed for more than 12 months, resulting in potential unidentified performance concerns and unmet care needs.
The facility failed to maintain an effective Infection Prevention and Control Program, with multiple instances of inadequate cleanliness and improper hand hygiene and glove use during incontinence care. Shared equipment was visibly soiled, and staff did not consistently follow infection control protocols, contributing to an increase in urinary tract infections and changes in residents' continence status.
The facility failed to ensure timely vaccination for five residents, as there was confusion among staff about who was responsible for tracking and updating immunizations. None of the residents had documentation of pneumococcal and/or influenza vaccines, nor were there any consents or declinations recorded, despite the facility's policy requiring such actions upon admission.
The facility failed to ensure proper documentation and offering of COVID-19 vaccinations to residents as per CDC guidelines. Interviews revealed confusion among staff regarding responsibility for tracking and updating immunizations, resulting in multiple residents not being in compliance with vaccination regulations.
The facility failed to effectively clean and maintain the physical plant, affecting 81 residents. Issues included non-functional light bulbs, soiled ventilation grills, missing countertop laminate edges, and soiled flooring surfaces. Interviews and record reviews revealed that the facility's preventative maintenance program was not effectively implemented, and housekeeping staff were not properly cleaning resident rooms and common areas.
The facility failed to maintain a dignified existence for three residents, resulting in long call light wait times, residents being left wet and soiled, and feelings of frustration, anxiety, and embarrassment. Residents reported waiting hours for assistance, leading to unsafe situations and discomfort. CNAs confirmed the long wait times and expressed awareness of the residents' frustrations.
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) for Medicare Part A services to three residents, resulting in potential unawareness of financial liability changes and delayed appeal ability. The residents were discharged after completing rehabilitation goals, but the facility did not provide the required NOMNC forms.
The facility failed to develop and implement comprehensive care plans for two residents, leading to potential harm. One resident, with severe cognitive impairment, did not have fall precautions consistently followed. Another resident, with a history of trauma from a fire, lacked a care plan addressing her trauma-related needs.
Failure to Prevent and Properly Manage Pressure Ulcers in a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure ulcer prevention and care for a high‑risk resident, resulting in the development and worsening of pressure injuries. The resident was originally admitted with intact skin and diagnoses including need for assistance with personal care and muscle weakness, and was care planned as having potential for impaired skin integrity related to traumatic brain injury. Interventions on the care plan included an alternating pressure mattress, heel elevation, daily skin observation with reporting of changes, and monitoring and documentation of any skin injuries. A Braden Scale assessment showed the resident was at high risk for skin breakdown. Despite this, multiple nursing admission and re‑admission screenings documented the resident’s skin as intact or with only dry skin, and did not record sacral or coccygeal skin issues that were identified in hospital records. Hospital documentation showed that a sacral wound was identified during a sepsis workup, with a small sacral wound draining purulent fluid and later a Grade 1 pressure ulcer to the coccyx. A subsequent hospital wound consult documented multiple pressure injuries, including an unstageable pressure injury and deep tissue pressure injuries to both heels, present on admission. When the resident returned to the facility, nursing re‑admission screenings again failed to document the coccyx/sacral wound, and early facility skin documentation on 11/11 described new in‑house gluteal abrasions without correlating them to the previously identified coccyx/sacral wound. Facility orders for wound care to the left gluteal abrasion were initiated on 11/12, and later progress notes and wound care practitioner assessments documented an unstageable coccyx pressure ulcer with slough and eschar, multiple pressure injuries to the coccyx/buttocks, heels, and elbows, and a decline of the coccyx area while in the hospital. By mid‑December, the left and right gluteal abrasions had combined into one coccyx wound, and the coccyx wound remained unstageable with a high percentage of slough and ongoing drainage. Interviews and record review revealed systemic failures in assessment, documentation, and implementation of care. The unit manager acknowledged that the coccyx wound and elbow wounds were first identified by the facility on 11/12 and that nursing re‑admission assessments on 10/27 and 11/5 did not indicate a coccyx pressure ulcer, attributing this to missed documentation. She also confirmed missing weekly skin assessments and shower sheets, despite expectations that staff complete skin checks twice weekly during showers and weekly nursing skin assessments. Multiple LPNs reported that the resident was dependent on staff for all care, including repositioning, and that he was not receiving regular showers, skin checks, or q2h repositioning as required, often due to short staffing. One LPN stated that staff commonly skipped care and treatments, and another confirmed that residents, including this resident, frequently missed treatments and care. The January treatment administration record for coccyx wound care showed nine instances of missing documentation for ordered treatments. Family reported that the resident had no skin issues on admission, required total assistance, and was not observed being repositioned or receiving care during frequent visits, and that concerns voiced to nursing, unit management, the DON, and social work were not effectively addressed. The facility’s own pressure ulcer policy required prevention of avoidable pressure ulcers and necessary treatment and services for existing ulcers, but the documented omissions in assessment, monitoring, repositioning, and treatment led to the identified deficiency.
Significant Medication Errors Involving Insulin and Antiepileptic Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically related to insulin administration for a resident with type 2 diabetes and antiepileptic medications for a resident with epilepsy. For the diabetic resident, the care plan identified a risk for blood sugar fluctuations and directed staff to administer medications as ordered, monitor blood glucose, follow hypoglycemia protocols, and report abnormal values to the physician. The resident’s insulin regimen was changed to include long-acting insulin at bedtime and scheduled short-acting insulin with meals plus a sliding scale. After this change, the resident experienced a first documented episode of severe hypoglycemia, during which an LPN found the resident non‑responsive with a critically low blood glucose and administered glucagon per protocol. The progress note for this event did not document that a provider was notified, and the medical director later confirmed he had not been made aware of this episode, nor had the insulin orders been reviewed or adjusted afterward. On a subsequent date, the same resident experienced another severe hypoglycemic episode. A CNA reported the resident felt hot, and when the LPN assessed the resident, she was diaphoretic and unresponsive with a blood glucose of 29. Multiple glucagon injections and oral glucose were administered with assistance from other nurses and a nurse practitioner, and the resident was ultimately sent to the hospital. Hospital records documented that the resident had been receiving 10 units of long‑acting insulin at night and 2 units of insulin with meals, and noted that hypoglycemia could be due to an insulin dosing error or accurate dosing in a patient not eating adequately. Review of the resident’s orders and MAR showed that the short‑acting insulin lispro was ordered as 7 units with meals plus a sliding scale, and that on the day of the second hypoglycemic event, the LPN administered 7 units of lispro at 10:32 a.m. for a blood glucose of 140 and then again at 1:05 p.m., giving 7 units plus 2 units per sliding scale for a blood glucose of 177. The LPN later acknowledged she was behind on medications, gave the morning and lunch insulin doses 2.5 hours apart, did not know whether the resident had eaten breakfast or lunch or how much was consumed, and did not realize the doses were so close together. The DON confirmed the insulin doses were given late and that nurses were expected to administer insulin with meals, check blood glucose before eating, and assess intake, while the medical director, PA, and pharmacist all stated they would be concerned about lispro being given 2.5 hours apart without knowledge of food intake. The second resident had a diagnosis of epilepsy and a care plan goal to remain free from injury related to seizure activity, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. MAR review showed that this resident missed multiple doses of Keppra and valproic acid over several days, including missed morning doses of Keppra and multiple missed doses of valproic acid on consecutive days. Progress notes documented that the resident refused morning medications on one day, that the nurse reapproached and the resident took only part of the medications, and that the resident’s family member expressed concern about lethargy, abnormal responsiveness, and the possibility of seizure, requesting hospital evaluation. The resident was sent to the hospital and returned with an increased Keppra dose, but subsequent notes indicated ongoing lethargy, refusal of meals, and refusal of medications. The resident later had seizure activity at the facility, and days afterward, staff documented that the resident had been unable to swallow food and medications for several days and that valproic acid was not given for this reason, leading to a provider notification and transfer to the emergency department. Hospital records for this resident described a history of TBI, epilepsy, and nonverbal status, with presentation for failure to thrive and significant dysphagia over 24–48 hours, during which the resident was unable to take medicines or oral intake. The family reported being told that oral antiepileptic medications drooled out of the resident’s mouth and could not be swallowed, and that the last seizure a few days prior was believed to be due to inability to take oral medications. The hospitalization summary noted status epilepticus and an acute ischemic infarction, and the attending physician stated that due to dysphagia the resident frequently missed antiepileptic doses, making breakthrough seizures unsurprising. Interviews with facility staff revealed that the LPN caring for the resident on one of the key days could not recall whether the provider was notified about missed Keppra and valproic acid doses, and the unit manager acknowledged she did not further investigate family concerns and confirmed multiple missed doses without documentation of provider notification. Another LPN reported being told by a CNA that the resident had been having swallowing issues and missing medications for days before she assessed the resident, notified the provider, and arranged hospital transfer. The DON and PA both stated that nurses were expected to notify providers whenever medications were missed or there was a change in condition, and review of records showed no documentation that providers were notified of the repeated missed antiepileptic doses due to dysphagia. Facility policies on medication administration required medications to be given as prescribed, within one hour before or after scheduled times, with before/after meal orders followed as written, and required explanatory notes and notification of the DON and physician when two doses of a medication were refused or withheld. The change in condition policy required that sudden or serious changes in condition be communicated to the physician with a request for prompt evaluation, and that all nursing actions be documented in progress notes. In both residents’ cases, the documented findings show that medications were not administered in accordance with physician orders and facility policy, that critical changes in condition and missed doses were not consistently communicated to providers, and that documentation of provider notification was lacking despite repeated episodes of hypoglycemia and missed antiepileptic doses associated with dysphagia and seizure activity.
Failure to Provide and Document Scheduled Showers and ADL Care for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and appropriate ADL care, particularly bathing and showering, to multiple dependent residents, and to accurately document refusals and care provided. One resident with a history of traumatic brain injury and total dependence for care was care planned as totally dependent on two staff for baths or showers twice weekly and as needed. Hospital records later documented that this resident was admitted soaked in urine, with a crusted right eye and crusting around the mouth. A family member reported visiting frequently for several hours at a time and never seeing staff assist with care, describing the resident as often disheveled, with peeling skin, soiled briefs, double briefs, and saliva on the mouth and face, and stated that scheduled showers were often missed despite repeated complaints to nursing staff, the unit manager, DON, and social worker. Review of shower sheets for a two‑month period showed only seven documented showers or bed baths when fourteen should have been provided or refusals documented. Staff interviews confirmed that showers and bed baths were frequently missed, especially when the facility was short staffed or when the designated shower aide was pulled to work the floor. Multiple LPNs reported that residents were missing showers due to staffing issues and that the shower aide was often reassigned, resulting in missed showers. A CNA stated it was very common to skip ADL care such as showers and bed baths because there was not enough time. The unit manager acknowledged awareness of the family member’s concerns, admitted that shower sheets were not consistently completed, and confirmed that she had not conducted follow‑up on ADL care after the resident’s hospital admission in soiled condition. The DON stated she was not aware of the family member’s concerns and indicated that unit managers were supposed to review shower sheets and care tasks daily. For other residents reviewed, records and interviews showed additional failures to provide scheduled showers and to document refusals. One male resident with multiple sclerosis, dementia, and weakness was care planned to receive showers twice weekly with assistance; task documentation showed a shower as given on a date when the shower sheet recorded a refusal, and there were no progress notes documenting refusals on that or another refusal date, despite multiple missed shower opportunities over 30 days. Another male resident with chronic pain, muscle weakness, wheelchair dependence, and long hair reported he did not get a shower every week and sometimes only every other week, especially when the shower aide was off; documentation across several months showed fewer showers than the scheduled opportunities, substitution of bed baths in some months, and missing progress notes for documented refusals. A female resident requiring setup and moderate to maximum assistance for bathing was scheduled for twice‑weekly showers but, over a 30‑day period, had only two showers and one refusal documented, with no corresponding refusal note in the progress notes despite nine scheduled opportunities. Another female resident with multiple sclerosis and overactive bladder reported that staffing ratios affected care, that it was difficult to get assistance, and that when the shower aide called in, floor CNAs did not complete scheduled showers; she also reported that the shower aide had too many showers scheduled to complete. The shower aide confirmed starting work very early, being pulled to the floor at least three times per week, and being unable to complete the high number of scheduled showers, resulting in residents not receiving showers on those days. The unit manager stated that when the shower aide was pulled, the assigned CNA was responsible for the shower and that refusals were to be re‑approached and documented with a nurse progress note, but the documentation reviewed did not consistently reflect this process.
Failure to Complete Timely PASRR Level I and II Evaluations for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely completion of PASRR (Preadmission Screening/Annual Resident Review) Level I and Level II evaluations for a resident with serious mental illness. The resident was a female with diagnoses including paranoid schizophrenia, dementia, and cognitive communication deficit. Her care plan, revised on 6/14/25, identified a behavior concern related to paranoid schizophrenia, noting that she might be paranoid about money and others’ opinions, potentially leading her to intrude on others’ privacy. Interventions included assisting her to develop appropriate coping and interaction methods, encouraging appropriate expression of feelings, anticipating and meeting needs, obtaining behavioral health consults as needed, and administering and monitoring psychotropic medications. Record review showed a Level II evaluation letter dated 1/5/25 stating that the resident could continue to reside in the nursing facility and may choose to receive specialized mental health/developmental disability services, with specialized services to be planned by the local community mental health agency. The letter indicated that a subsequent Level II evaluation would need to be completed by 1/4/26. During an interview, the Social Services Director reported that the Level II evaluation due by 1/4/26 was not available and that she was unsure whether the OBRA evaluator, who had been in the facility on 2/19/26, had seen this resident. She also stated that Level I evaluations were completed yearly and with changes in condition. Electronic correspondence from the Nursing Home Administrator confirmed that a Level I was completed on 12/5/24 and a Level II on 1/5/25, but there was no Level I documented for 2025, demonstrating that required PASRR evaluations were not completed timely for this resident.
Failure to Implement Care Plan Interventions for Fall Prevention and Eating Assistance
Penalty
Summary
Surveyors identified a failure to implement comprehensive care plan interventions for multiple residents, resulting in care not being provided as planned. One male resident with multiple sclerosis, dementia, anxiety, weakness, a history of repeated falls, and other psychiatric diagnoses had a care plan focus on limited physical mobility and fall risk, with specific interventions including use of a pillow or rolled blanket to define bed borders and a wedge or body pillow to prevent him from leaning or falling from the bed. On multiple observations over several days, the resident was seen lying in bed leaning to the right side without any pillow, blanket, or wedge in place, and at one point his right arm and shoulder were off the side of the mattress while a blue wedge was observed on the bedside table instead of in use on the bed. Another female resident with dementia, osteoporosis, and multiple sclerosis had a care plan identifying her as at risk for falls due to a high desire for independence, challenged balance and coordination, low safety awareness, and a tendency to lean forward when propelling herself in a wheelchair. Following an incident where she was found sitting on the floor after sliding while attempting to transfer from bed to wheelchair without staff assistance, the plan of care was updated to include a non-slip dycem pad to the side of her bed. However, during multiple observations, no dycem was found on or under the sheets on the exit side of the bed. The resident stated she did not know what a dycem was and that there was none on her bed. A CNA and an LPN both reported they had not seen a dycem on the bed and were unaware of the intervention, despite the Kardex indicating its use, and staff interviews confirmed that the dycem was not being implemented as planned. A third resident with type 2 diabetes mellitus had a care plan indicating an ADL self-care performance deficit, with a goal to improve self-care and an intervention specifying that she required assistance with eating. Progress notes documented that she required assistance with feeding and was only eating bites of her meals. Despite this, facility documentation for multiple dates recorded her as independent with eating or needing only setup assistance. Several LPNs and a CNA reported that the resident always ate in her room and generally did not receive assistance with eating, although some staff had noticed she did not eat well and seemed to need help. One LPN stated she did not know the care plan required assistance with eating and another reported the resident did not require such assistance. During observation, the resident was seen in her room attempting to eat independently, struggling to scoop food onto her fork and unable to cut her chicken, with no staff present to assist her, contrary to the care plan intervention.
Failure to Assess Ongoing Need for Indwelling Foley Catheter
Penalty
Summary
The deficiency involves the facility’s failure to assess and act on the continued need for an indwelling Foley catheter for one resident following a urology visit. The resident was originally admitted with diagnoses including essential hypertension and had a history of renal stones and a ureteral stent. A urology After Visit Summary dated 6/25/25 documented instructions that it was acceptable to remove the Foley catheter and to replace it only if the resident was unable to void after six hours or had a post-void residual greater than 250. Despite these written instructions, the catheter remained in place for months, and there is no documentation that facility providers assessed whether the catheter was still necessary after the June 2025 appointment. During the months following the urology visit, the resident repeatedly experienced problems with the catheter, including leaking and pain. Progress notes show that on 9/29/25 the resident complained of leaking around the Foley, with the bed noted to be wet with urine; the nurse removed the old Foley, encountered resistance and a blood clot during reinsertion, and then placed a new catheter, after which the resident reported feeling better. On 10/1/25, the resident again reported leaking from the insertion site, and the nurse flushed the catheter and adjusted the balloon to stop the leaking. On 10/6/25, the resident again reported leaking; the nurse deflated and repositioned the balloon, flushed the line, and observed all saline leaking from the insertion site. Multiple attempts by two nurses to reinsert a new catheter were unsuccessful due to resistance, and the resident was then allowed to void without a catheter, using briefs while staff monitored output and possible retention. Interviews confirmed that key staff and providers did not assess the ongoing need for the catheter after the June 2025 urology visit. The resident reported that he had the Foley catheter for months after the appointment, had asked staff several times to see if he still needed it, and felt the facility did not act promptly, causing frustration and pain from frequent leaking and discomfort. The Unit Manager stated she was unsure whether the catheter was supposed to be removed after the June visit, acknowledged that the urology note indicated removal was acceptable, and could not recall why the facility had not removed it or whether facility providers had assessed the need for continuation. The Medical Director reported he had not assessed the resident to determine if the Foley was still needed and did not see the resident often enough to comment on why it remained in place. The PA believed the resident had urinary retention, had not assessed whether the catheter could be removed, and was unaware that the catheter had already been discontinued until informed during the interview.
Improper Oral Water Administration to NPO PEG-Fed Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide care consistent with professional standards for a resident receiving enteral nutrition who was ordered NPO with PEG tube feeding for all nutrition, hydration, and medications. The resident had a history of stroke, malnutrition, dehydration, GERD, dysphagia, aphasia, anemia, and failure to thrive, with a speech evaluation documenting moderate oral dysphagia and clinical signs of pharyngeal dysphagia. The care plan identified swallowing and nutritional problems, including use of enteral feedings via PEG and an NPO status, with interventions specifying tube feeding as ordered and diet to be followed as prescribed. Despite these orders and assessments, staff were observed providing water orally to the resident using sponge-tipped mouth swabs. A CNA repeatedly dipped a mouth swab into a Styrofoam cup of water and placed it into the resident’s mouth multiple times without squeezing out excess water, while the resident sucked water from the sponge. The CNA stated that the resident had requested water several times that morning and that she had given him water with the swab each time he asked. Another CNA reported that the resident was on a fluid restriction, was NPO, and received water via his feeding tube, and that staff were supposed to use lemon mouth swabs to keep his mouth moist because he could not have anything by mouth. Additional observations and interviews showed that the resident continued to request water, that lemon swabs were intended to be used in place of water due to his NPO status, and that there was no specific order for mouth swabs, with oral care treated as a standard of care. A physician progress note documented that a full cup of water had been found at the bedside of this NPO resident with a PEG tube, with nursing staff reporting it was for oral care. Another progress note described the resident with brown-colored emesis on his gown and linens, with tube feeding held pending evaluation for possible obstruction. The unit manager confirmed the resident should not have received water because he was not swallowing and that oral care directions in the Kardex and care plan were unclear, noting that brushing his teeth and rinsing could result in aspiration.
Failure to Maintain Complete and Accurate Treatment and Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, as required by its own charting and documentation policy. For one resident with muscle weakness and a need for assistance with personal care, the January 2026 Treatment Administration Record (TAR) showed missing documentation for several ordered treatments. These included wound care to a ruptured blister on the left inner knee with no documentation on one date, wound care for a right forearm skin tear with missing entries on two dates, use of bilateral pressure-relieving boots with no entry on one date, catheter care with no entry on one date, G-tube placement checks with no entry on one date, and coccyx wound care with missing documentation on five separate dates. The TAR did not indicate whether these treatments were completed or refused on the listed dates. Another resident with type 2 diabetes mellitus and pneumonia had incomplete documentation on the February 2026 TAR. There was no recorded entry for a morning pulse oximetry assessment on one date, despite an order related to pneumonia. Wound care orders for a right medial gluteal community-acquired stage 3 (now unstageable) pressure injury, requiring cleansing with normal saline, application of hydrogel, and border gauze every shift, lacked documentation on three dates. Additionally, ordered betadine application to a community-acquired unstageable deep tissue injury (DTI) on the left heel was not documented on two dates, and required checks of the oxygen concentrator for proper function and flow rate every shift were not documented on one date. The TAR did not show whether these treatments and checks were completed or refused. A third resident with repeated falls, multiple sclerosis, dementia, anxiety, and weakness had no weekly skin assessments documented for multiple specified weeks in November and December 2025. Interviews with nursing staff indicated that weekly skin assessments were expected to be completed to identify changes in skin condition, and that these assessments appeared in the electronic record as UADs (assessments) to be completed by nurses. Staff reported that UADs could be skipped and reassigned, and that if not completed within 24 hours they would disappear from the alert system. The DON stated that unit managers were supposed to review shower sheets and resident care tasks daily and follow up on missed documentation or care, and that nurses were expected to document any missed treatment with an explanation in a progress note, but such documentation was not present for the missed treatments and assessments identified.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
A resident with a history of a sacral pressure ulcer and high risk for skin breakdown was not provided with adequate care to prevent the worsening of pressure ulcers. The resident was observed lying flat on her back with her heels pressed against the bed surface, despite care instructions to elevate her heels and reposition every two hours. The resident reported pain and burning from a wound on her buttocks, and stated that staff did not always have the necessary cream available during care. Documentation showed a significant increase in the size of a right gluteal Stage 3 pressure ulcer over a short period, with the wound progressing from a small, stable area to a much larger, fragile, and declining wound with eschar and active bleeding. Staff interviews and observations revealed multiple lapses in care. Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) were unaware of the resident's wounds, did not consistently check on the resident, and failed to maintain enhanced barrier precautions as required for infection control. The resident's wound was not covered with a bandage as ordered, and barrier cream was not always available or applied as needed. Incontinence care was not performed properly, with the resident experiencing repeated episodes of catheter leakage that left her clothing and bedding wet. Staff were observed pulling linens out from under the resident, which can cause shearing and further skin breakdown, and did not consistently use gowns and gloves as required. Further, there was a lack of communication and awareness among staff regarding the resident's wound status and care needs. Some staff had not seen the wound, and wound care orders were not consistently followed. The resident, who was cognitively intact, reported ongoing pain and inadequate care. The failure to provide proper wound care, repositioning, incontinence management, and infection control measures resulted in actual skin breakdown and worsening of the resident's pressure ulcers.
Failure to Timely Implement Hospital Discharge Medication Orders on Admission
Penalty
Summary
Nursing staff failed to ensure that a newly admitted resident received care in accordance with professional standards by not implementing hospital discharge medication orders in a timely manner. The resident, who had diagnoses including gastroparesis, returned from the hospital with a comprehensive list of prescribed medications for various conditions such as nausea, vomiting, pain, and heartburn. Upon admission, the responsible LPN entered the medication orders into the computer system but did not complete the process required to transmit these orders to the pharmacy, as a second nurse was expected to confirm and activate the orders. As a result, the pharmacy did not receive the medication orders on the day of admission. The delay in confirming and activating the medication orders led to the resident missing multiple scheduled doses of essential medications, including those for nausea, pain, and other chronic conditions. The resident reported not receiving her prescribed medications for nausea and vomiting, which resulted in her being readmitted to the hospital two days after her initial return to the facility. Documentation confirmed that several doses of medications were missed during this period, as the pharmacy only received the orders the following morning after another nurse discovered the oversight and activated the orders. Interviews with nursing staff and pharmacy personnel revealed that the facility's process required a double-check and activation of new medication orders before they could be sent to the pharmacy. However, this step was not completed by the night shift nurse, leading to a significant delay in medication administration. The resident's care was compromised due to the failure to follow established procedures for timely medication order processing and administration upon admission.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Facility staff failed to implement physician orders for Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer and a urinary catheter. The resident's medical record indicated the need for gloves and gowns during high-contact care activities such as dressing, bathing, toileting, personal hygiene, transferring, changing linens, and wound care. Despite these orders, observations revealed that a CNA and an LPN provided direct care, including incontinence care and wound care, without donning gowns as required by EBP protocols. Additionally, the unit manager assisted with repositioning the resident without wearing a gown, even though she acknowledged the resident required EBP due to wounds and catheter use. The need for EBP was not posted at the resident's door. The resident was found with a large, non-blanchable area and an open wound on the buttocks, and the wound had significantly worsened between assessments. The resident also experienced issues with catheter placement, resulting in urine backflow and soiled clothing and bedding. Staff failed to maintain EBP during these care activities, as observed by surveyors, and the required precautions were not consistently communicated or posted for staff awareness.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in its kitchen and food service areas, affecting 84 residents. During a comprehensive tour of the kitchen, it was observed that one of the hand sink basins was draining slowly, and several plastic utensils were stored uncovered, exposing them to potential contamination. Additionally, food transportation carts, a coffee machine, and a refrigerator door gasket were found to be soiled with accumulated food residue, indicating a lack of effective cleaning and maintenance of food service equipment. Further inspection revealed that several food items were not properly labeled or dated, increasing the risk of foodborne illness. Two containers of sour cream and a gallon of milk were found without effective open or discard dates, and some items were past their best-by dates. The facility's policy on date marking for food safety was not adhered to, as evidenced by the presence of expired and improperly labeled food items in the walk-in cooler and nourishment room. Additional deficiencies were noted in the storage and handling of food products. Opened bags of chocolate chips, cake mix, and spaghetti pasta were not securely sealed, and a case of bread was stored on the freezer floor. In the walk-in cooler, an uncovered plate with a half-eaten piece of cheesecake and a container of cut-up lettuce without labels or dates were found. The facility's failure to follow its policies on food receiving, storage, and sanitation contributed to the increased potential for cross-contamination and bacterial harborage, posing a risk to resident health and safety.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a clean and safe environment, affecting 84 residents, as observed during an environmental tour. Several areas, including service corridors, janitor closets, and common rooms, were found to be in disrepair and unclean. Specific issues included corroded and soiled appliances in the staff break room, missing laminate on countertops, loose fixtures, and heavily soiled ventilation grills. Additionally, the flooring in multiple janitor closets and the oxygen supply closet was soiled with dust and dirt deposits, and several pieces of furniture were damaged or dirty. Interviews with maintenance aides revealed that the facility uses the TELS program for maintenance work orders, but no specific entries related to the observed maintenance concerns were found in the records for the last 60 days. The facility's policies and procedures for preventative maintenance and housekeeping were reviewed, indicating a lack of adherence to established guidelines for maintaining a safe and sanitary environment. The deficiencies noted during the survey highlight a significant lapse in the facility's environmental services and maintenance practices.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet needs in areas such as incontinence care, pressure ulcer prevention, skin integrity, respiratory care, and overall wellness. Resident #13, who was cognitively impaired and dependent on staff for personal hygiene, was at high risk for pressure sores but lacked a care plan addressing this risk. Observations revealed that Resident #13 was not repositioned regularly, and incontinence care was not provided timely, resulting in prolonged periods of wetness and potential skin damage. Resident #38, who was receiving hospice services, did not have these services reflected in their care plan, indicating a lack of coordination between hospice care and the facility's care planning. This oversight could lead to inadequate end-of-life care and support for the resident and their family. Similarly, Resident #44, who was at very high risk for pressure sores and had a history of traumatic brain injury and aphasia, did not have a care plan addressing their high risk for pressure sores or the use of palm protectors and arm elevation for contracture prevention. Resident #76, who had obstructive sleep apnea and used a CPAP machine, did not have a care plan that included the use and maintenance of the CPAP machine. Observations showed that the CPAP equipment was heavily soiled and not properly maintained, despite documentation indicating it had been cleaned. This discrepancy suggests a failure in the facility's processes for ensuring the proper care and maintenance of medical equipment, potentially compromising the resident's respiratory health.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to provide palatable and appropriately temperature-controlled food to its residents, as evidenced by observations and interviews. During a survey, it was noted that food trays were delivered to various halls and dining areas, with the Main Dining Room being served last. Food temperatures were recorded using a digital thermometer, revealing that several food items, such as pork fritters, mashed potatoes, and peas, were below the required temperature of 135°F, as per the 2022 FDA Model Food Code. Additionally, beverages like coffee and milk were not maintained at safe temperatures, potentially affecting the residents' food acceptance and nutritional status. Interviews with residents and staff highlighted ongoing issues with food quality and temperature. Resident #17, who is cognitively intact, reported that the food, especially during evening meals, was not hot enough and mentioned an incident where an egg sandwich was undercooked. The Dietary Manager confirmed the complaint and acknowledged that residents have raised concerns about food temperatures. Similarly, Resident #45, also cognitively intact, expressed dissatisfaction with the cold food served in her room and had previously communicated these concerns to the Dietary Manager. The facility's policies on maintaining sanitary tray lines and proper food portioning and plating were reviewed, indicating a commitment to safe food handling and appealing presentation. However, the lack of plate warmers and a food committee for residents to voice their concerns were noted as contributing factors to the deficiency. A confidential group meeting with 11 residents further corroborated the issue, with unanimous agreement that the food was not served hot enough, was of poor quality, and often had missing items.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor resident food choice preferences, impacting several residents. Resident #63 expressed dissatisfaction with receiving food items listed as dislikes on her meal card, such as gravy and peas. The facility's policy mandates that food served should accommodate residents' allergies, intolerances, and preferences, with alternative options available. However, this policy was not adhered to, as evidenced by the meal card review and resident interviews. Resident #44, who has a traumatic brain injury and aphasia, received food items that were not consistent with her dietary preferences, such as whole peas and applesauce, despite her meal tray ticket indicating these as dislikes. Additionally, Resident #73, who is mildly cognitively impaired, reported receiving smaller portions than requested, leading to significant unintentional weight loss. The resident's meal ticket indicated a preference for large portions, which was not consistently honored. Other residents, such as Resident #17 and Resident #21, also experienced issues with meal preferences not being met. Resident #17 reported frequent substitutions without prior notice, and Resident #21 did not receive requested items like grapes, with no alternatives offered. The facility's failure to provide meals according to residents' preferences and dietary needs was further corroborated by a confidential group meeting where residents reported missing items on their meal trays.
Infection Control Deficiencies in Glove Use and Equipment Sanitation
Penalty
Summary
The facility failed to ensure proper glove use during incontinence care and injection administration, and sanitary storage of respiratory equipment, affecting three residents. Resident #13, who was cognitively impaired and dependent on staff for personal hygiene, was observed receiving incontinence care with improper glove use. CNA P used soiled gloves to apply barrier cream and wash the resident's peri area, violating standard infection control practices. Additionally, the resident's urine test results were pending, and there was a history of severe UTIs. Resident #44, diagnosed with traumatic brain injury and aphasia, was also subject to improper glove use. CNA Q was observed handling clean objects and opening the door while still wearing soiled gloves after providing peri care. This action posed a risk of cross-contamination and did not adhere to proper infection control protocols. Resident #76, with obstructive sleep apnea, had a CPAP machine that was heavily soiled and improperly stored. The machine was observed running with the hose on the ground and the mask on the bed, contrary to the facility's cleaning and storage orders. The resident reported that the machine was not cleaned, and the Director of Nursing confirmed the equipment's poor condition. Additionally, an LPN was observed administering an insulin injection without gloves and failed to perform hand hygiene, further compromising infection control standards.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by multiple observations and interviews. Resident #13, who was cognitively impaired and dependent on staff for personal hygiene, was observed with wet pants and crumbs on his shirt. Despite his non-verbal cues indicating discomfort, staff members, including a CNA and the Director of Nursing, failed to address his needs promptly. The resident's use of a pocket talker for hearing was overlooked, and his incontinence was not managed in a timely manner, leading to prolonged discomfort. Resident #44, who had a traumatic brain injury and aphasia, was also subjected to a lack of dignity during care. While being transferred and receiving incontinence care, CNAs conversed with each other rather than engaging with the resident, who could hear but not speak. This behavior was noted as disrespectful, as the staff did not acknowledge the resident's presence or attempt to communicate with him during care. Resident #54 reported experiencing pain and difficulty sleeping, and when seeking assistance, was met with a dismissive attitude from a nurse. The nurse expressed frustration about her workload before addressing the resident's request for pain medication. Additionally, a group meeting with 11 residents revealed widespread dissatisfaction with the staff's treatment, citing issues such as unfamiliarity with resident needs, personal phone use, and inadequate attention during night shifts.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents did not self-administer medications without a proper assessment of their ability to do so safely. During an observation, Resident #28 was found with a medication cup containing five pills left on their tray table, which the resident reported was left by a nurse for later consumption. There was no assessment or orders in the record for Resident #28's self-administration of medications. Similarly, Resident #69 was observed with a medication cup in the hall and was unsure about one of the pills, which was identified by an LPN as a pancreatic enzyme pill. The LPN mentioned that Resident #69 was alert and could self-administer medications, but there was no assessment or orders in the record to support this. The Director of Nursing confirmed that no residents in the facility were assessed to self-administer medications, and staff were expected to supervise medication intake to ensure compliance.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to investigate an allegation of abuse for Resident #37, who reported that a staff member bent his thumbs backward, causing ongoing pain and difficulty in gripping objects. Despite the resident informing management, there was no documentation or investigation into the incident. Interviews with staff revealed a lack of awareness and communication regarding the allegation, with the Director of Nursing (DON) unable to locate any records or statements related to the incident. For Resident #49, the facility did not provide an accurate investigation into an allegation of abuse involving a CNA potentially restraining the resident during care. The resident, who was known to be combative due to Alzheimer's, was reportedly held down by a CNA while other staff assisted with incontinence care. Witnesses described the CNA's actions as abusive, including holding the resident's arms and covering his face with a soiled sheet. Despite these reports, the facility's investigation summary did not include all witness statements and concluded that the event was not a result of abuse or neglect. The facility's failure to thoroughly investigate these allegations and accurately document witness accounts resulted in the potential for further abuse. The lack of communication and proper documentation among staff, as well as the incomplete investigation, highlights deficiencies in the facility's handling of abuse allegations.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to notify two residents and their representatives of the bed hold policy in writing upon their transfer to a hospital, as required by the facility's policy. Resident #37, who was cognitively intact, was transferred to the hospital on two occasions, once for a headache due to a fall and another time for lethargy and difficulty maintaining oxygen levels. However, there was no documentation that Resident #37 received a written bed hold notice on either occasion. Interviews with the Director of Nursing and Licensed Practical Nurses confirmed that a bed hold form should be provided at each hospital transfer, but the Nursing Home Administrator admitted that the documentation could not be located for the specified dates. Similarly, Resident #43 was transferred to an acute care hospital at the request of his wife due to his lack of appetite and failure to return to his baseline condition. The facility's records did not contain any documentation of a bed hold notice being provided to Resident #43 or his representative prior to the transfer. An email inquiry to the Nursing Home Administrator confirmed that the documentation could not be found. The facility's bed hold policy, revised in 2019, mandates that a copy of the policy be provided to the resident and their representative before and during transfers for hospitalization or therapeutic leave.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards for medication administration, specifically during an insulin injection for Resident #332. During an observation, an LPN was seen administering an insulin injection without wearing gloves and subsequently did not perform hand hygiene after the procedure. The LPN then proceeded to another resident's room without performing hand hygiene, where she discussed pain medication and handled a meal tray. In an interview, the LPN stated that she did not wear gloves or perform hand hygiene because she believed there was no exposure to blood or body fluids. According to the Centers for Disease Control, gloves should be worn during procedures involving potential exposure to blood or body fluids, and hand hygiene should be performed immediately after glove removal and before touching other medical supplies intended for use on other persons.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care to two residents, resulting in unmet care needs and an unkempt appearance. Resident #19, who was admitted with diagnoses including localized edema and aphasia following a cerebral infarct, was observed multiple times without her prescribed ted hose, which were ordered to be worn every morning and removed at night. Despite documentation in the medication administration record (MAR) indicating that the ted hose were applied, observations and interviews confirmed that they were not. The Licensed Practical Nurse (LPN) responsible for documentation admitted to not verifying the application of the ted hose, relying instead on the Certified Nurse Assistants (CNAs) to perform this task. Resident #76, who was cognitively intact and required substantial assistance for personal hygiene, reported not receiving a shower for approximately 2-3 weeks and had not been assisted with shaving during that time. Observations noted that Resident #76 had a soiled shirt, messy hair, and overgrown facial hair. The resident expressed a desire for regular showers and basic hygiene assistance, such as washcloths for daily cleaning. Despite being scheduled for a shower, the resident reportedly refused due to the early timing, and the Shower Aide (SA) did not have a shaver available during previous showers. The facility's failure to ensure the application of ted hose for Resident #19 and to provide regular showers and hygiene assistance for Resident #76 highlights a deficiency in meeting the residents' ADL needs. The Director of Nursing (DON) confirmed the expectation that nurses should verify and document the application of ted hose, which was not adhered to in this case. Additionally, the lack of consistent hygiene care for Resident #76 was evident, as the resident had not received regular showers or basic hygiene support, leading to an unkempt appearance.
Failure to Prevent Pressure Ulcers in At-Risk Residents
Penalty
Summary
The facility failed to provide preventative care consistent with professional standards for two residents at risk of developing pressure injuries. Resident #13, who was cognitively impaired and dependent on staff for all toileting and personal hygiene needs, was identified as being at high risk for pressure sores with a Braden Scale score of 11. Despite this, there was no care plan developed for pressure sore risk or preventative interventions. Observations revealed that Resident #13 was left in a broda chair for extended periods without repositioning, and staff failed to check or change the resident's incontinence brief, resulting in wetness and potential skin damage. Resident #44, who was severely impaired and completely dependent on staff for mobility and hygiene, had a Braden Scale score of 9, indicating a very high risk for pressure sores. However, the care plan lacked information related to pressure sore prevention. Observations showed that Resident #44 was left in a broda chair for prolonged periods without repositioning or offloading pressure from the heels, contrary to the facility's protocol of repositioning every two hours. The resident was also found with a bulging incontinence brief and wet pants, indicating a lack of timely incontinence care. Interviews with staff, including the Director of Nursing, confirmed that both residents should have been repositioned every two hours and checked for incontinence regularly. The facility's failure to implement these preventative measures and adhere to care plans for pressure sore prevention resulted in the potential for the development of avoidable pressure ulcers, infection, and overall deterioration in health status for both residents.
Failure to Use Gait Belts and Wheelchair Foot Pedals
Penalty
Summary
The facility failed to ensure safe transport and transfer practices for residents, leading to potential injury risks. Resident #63, who was cognitively intact and had a history of repeated falls and weakness, was observed being transported in a wheelchair without foot pedals, requiring her to hold her feet off the floor. Additionally, during transfers to and from the commode, the Certified Nurse Assistant (CNA) did not use a gait belt, despite the facility's policy and the presence of gait belts in the resident's room. Interviews with various staff members, including the CNA, Licensed Practical Nurse (LPN), Registered Nurse/Unit Manager (RN/UM), and Director of Nursing (DON), confirmed that gait belts should be used for all transfers that do not require a mechanical lift, and foot pedals should be in place when pushing a wheelchair. Resident #37, who had multiple diagnoses including acute respiratory failure and COPD, experienced a fall when a new CNA did not use a gait belt during a transfer. The incident report indicated that the resident was found on the floor after attempting to sit down before the CNA had finished changing his brief. The CNA, who was recently hired, had received education on the use of gait belts following the incident. Interviews with the DON confirmed that the CNA should have used a gait belt during the transfer, as per facility policy.
Failure in Timely Incontinence Care and Infection Control
Penalty
Summary
The facility failed to provide timely incontinence care and perform hand hygiene according to standard infection control practices for two residents, resulting in potential risks for skin breakdown and urinary tract infections. Resident #13, who was cognitively impaired and dependent on staff for all toileting and personal hygiene needs, was observed in a wet incontinence brief for an extended period. Despite multiple observations and interactions with staff, the resident's needs were not addressed promptly. The resident was left in a broda chair for long periods without being checked or changed, and staff failed to reposition him as required. Additionally, when incontinence care was eventually provided, proper hygiene practices were not followed, as gloves were not changed between tasks, and the resident was not cleaned from front to back. Resident #44, who was severely impaired and completely dependent on staff for toileting and personal hygiene, was also left in a wet incontinence brief for an extended period. Observations revealed that the resident remained in the same position for hours without being checked or changed. Despite the presence of staff on the hall, no care was provided to the resident until a family member expressed concern about the resident being soaking wet. The facility's failure to adhere to the care plan, which required checking and changing the resident every two hours, contributed to the deficiency. The report highlights the facility's failure to provide adequate incontinence care and adhere to infection control practices, as evidenced by the prolonged periods during which both residents were left in wet briefs. The lack of timely care and proper hygiene practices poses a risk for skin breakdown and urinary tract infections, particularly for residents with a history of severe UTIs, like Resident #13. The observations and interviews with staff and family members underscore the facility's shortcomings in meeting the residents' needs and following established care protocols.
Failure to Maintain Sanitary CPAP Equipment
Penalty
Summary
The facility failed to maintain and store CPAP equipment in a sanitary manner for a resident with obstructive sleep apnea, leading to an increased potential for respiratory infection and distress. The resident, who was cognitively intact, had a CPAP machine upon admission, with orders for daily cleaning and maintenance. However, observations revealed that the CPAP machine, hose, and mask were heavily soiled with dirt and grime, and the water container was empty with a dried white substance. The resident reported that the CPAP machine was not being cleaned, and a registered nurse did not address the running machine or offer assistance during a medication administration. The Director of Nursing confirmed that the CPAP machine should be cleaned weekly by nursing staff and that there were orders to ensure proper use and storage of the equipment. Despite these orders, the resident's care plan did not indicate the use of a CPAP machine or the presence of sleep apnea. The Director of Nursing observed the soiled equipment and acknowledged the inability to clean it, indicating a need for replacement by the durable medical equipment company.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications were limited to 14 days unless a documented rationale by the physician was present in the medical record. This deficiency was identified in the case of a resident who was admitted with diagnoses including PTSD, bipolar disorder, anxiety disorder, and dementia. The resident was cognitively intact, as indicated by a BIMS score of 15/15. The resident was receiving Xanax twice daily and Ativan at night. A physician's recommendation suggested treating the resident's anxiety with a single medication and attempting a gradual dose reduction or discontinuation of Xanax. However, the physician's order dated 12/30/2024 for Xanax as needed did not include a 14-day limit or a stop date, and there was no documented rationale for extending the PRN order beyond 14 days. The facility's policy requires that PRN psychotropic medications be limited to 14 days unless the attending physician documents a reason for extension in the resident's medical record. The Social Services Director confirmed that the order did not comply with this policy, as it lacked a stop date and documented rationale for the extended use.
Failure to Protect Resident from Abuse During Care
Penalty
Summary
A resident with Alzheimer's disease, who was known to be resistant and combative during activities of daily living (ADL) care, was subjected to inappropriate handling by staff during incontinence care. The resident's care plan specified that if the resident resisted care, staff should reassure the resident, ensure a safe environment, leave, and return later to try again. Despite these instructions, three CNAs proceeded with care while the resident was combative, with one CNA holding the resident's hands to his chest while the others performed care. This action was not in accordance with the care plan's de-escalation strategies. Multiple staff interviews revealed that the CNA at the head of the bed pinned the resident's arms down, verbally engaged with the resident in a confrontational manner, and covered the resident's head and arms with a soiled sheet to facilitate rolling the resident. Other CNAs present objected to this treatment, repeatedly asking the CNA to stop, and one removed the sheet from the resident. Both CNAs who witnessed the incident reported the behavior as abusive to the charge nurse and subsequently felt threatened by the facility administrator, leading them to resign. The incident was reported to facility leadership, but the CNA accused of abuse continued to work on the floor until the Director of Nursing and the Nursing Home Administrator arrived and suspended her. The LPN on duty was unsure of the protocol for removing the accused CNA from resident care and did not intervene immediately. The actions taken by the staff during care, including physical restraint and verbal intimidation, were inconsistent with the resident's care plan and failed to protect the resident from abuse.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to implement its policies and procedures for reporting an allegation of abuse involving a resident, leading to a potential delay in investigation and further abuse. The incident involved a resident who was admitted to the facility with a diagnosis of kidney failure. The resident alleged that he had been kicked by a staff member, resulting in cracked ribs, and was subsequently admitted to the hospital. The resident's BIMS score indicated that he was cognitively intact, which supports the credibility of his allegation. The deficiency occurred when the Nursing Home Administrator (NHA) was informed of the abuse allegation at approximately 1:00 AM but did not submit the Facility Reported Incident (FRI) until 10:39 AM, about 10 hours later. This delay in reporting was despite the fact that the resident had already been discharged to the hospital and had sustained injuries. The Social Worker and Registered Nurse involved in the case reported the allegation to the NHA promptly, but the NHA's delayed action in submitting the FRI contributed to the deficiency.
Inadequate Supervision Leads to Repeated Falls and Injuries
Penalty
Summary
The facility failed to provide adequate supervision for three residents at risk for falls, resulting in repeated falls and injuries. Resident #114, who was admitted with diagnoses including kidney failure, experienced multiple falls within a short period. Despite being identified as high risk for falls, interventions such as medication review and room relocation were insufficient. The resident sustained a cervical fracture and later acute rib fractures, indicating a lack of effective supervision and timely intervention. Resident #108, with partial paralysis following a stroke, also experienced multiple falls. Despite being assessed as high risk for falls, the resident was found on the floor several times, including incidents where they were injured. The facility's response included relocating the resident to common areas for monitoring, but this did not prevent further falls, highlighting inadequate supervision and staffing issues. Resident #106, diagnosed with dementia, was identified as high risk for falls and experienced numerous falls. The interventions implemented, such as placing the resident in common areas and using gripper socks, were not sufficient to prevent falls. Observations revealed the resident was left unsupervised for extended periods, and interviews with staff indicated that staffing levels were inadequate to provide necessary supervision, contributing to the repeated falls.
Inadequate Staffing Leads to Multiple Resident Falls
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, particularly those at risk for falls. The staffing issues were highlighted by the experiences of three residents who suffered multiple falls due to inadequate supervision. The facility's scheduler reported that staffing was based on census numbers, and there was a reliance on agency nurses, but not on Certified Nursing Assistants (CNAs). On the third shift, the facility was understaffed, with only one CNA assigned to each hall and a float CNA who was not always available. This resulted in CNAs being overwhelmed and unable to provide adequate supervision, especially for residents requiring two-person assistance. Resident #114, residing on the rehab hall, experienced several falls due to insufficient supervision. The rehab hall was not visible from other areas, and staff were often required to assist on other halls, leaving the rehab hall unsupervised. On multiple occasions, Resident #114 fell while staff were attending to other duties, and there was a delay in assistance. The resident suffered a significant injury, including a fracture of the cervical vertebrae, after one of the falls. Resident #108 was also affected by the staffing shortage, as he was restless and frequently attempted to get out of bed. With only one CNA on the south hall during the third shift, staff were unable to monitor him adequately, leading to several falls. Similarly, Resident #106, who was at risk of falling, was often left unsupervised due to the limited number of CNAs available to assist with residents requiring two-person assistance. The facility's reduction in staff numbers exacerbated the situation, making it difficult for staff to provide the necessary care and supervision to prevent falls.
Inadequate Provision of Evening Snacks
Penalty
Summary
The facility failed to consistently offer or provide hour of sleep (HS) snacks to two residents, resulting in dissatisfaction. Resident #102 reported the unavailability of snacks in the evening, while Resident #113 noted that snacks were limited and not offered unless a resident's name was on a list. Staff interviews revealed that sandwiches were unavailable after the kitchen closed at 8:00 PM, and snacks were primarily provided for diabetic residents. Staff sometimes resorted to purchasing snacks from vending machines or external sources to meet residents' requests. The Dietary Manager acknowledged a reduction in evening kitchen staff, which affected the timely delivery of meals and snacks. Observations of nourishment rooms showed limited availability of snacks, with some rooms being locked or used for personal food storage. The Director of Nursing was unaware of the issue, despite reports from multiple staff members indicating a lack of snacks for non-diabetic residents and insufficient stocking of nourishment rooms. This deficiency highlights a gap in the facility's ability to meet residents' needs for snacks outside of scheduled meal times.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with chronic wounds or indwelling medical devices, leading to potential transmission of multidrug-resistant organisms (MDRO). For Resident #112, during an observation, it was noted that Certified Nursing Assistants (CNAs) were not wearing gowns or gloves while repositioning and transferring the resident, despite the presence of a wound vac on the resident's heel. Interviews with the CNAs and the Infection Preventionist (IP) revealed a misunderstanding of the EBP requirements, as they believed PPE was only necessary during wound care when the wound was uncovered. For Resident #115, the observation showed that a CNA was not wearing a gown while changing the resident's incontinence brief, although gloves were used. The CNA expressed confusion about PPE usage due to the absence of a PPE cart in the hallway. The IP clarified that Resident #115 was not on contact precautions, and the signage would be updated to reflect EBP for the resident's chronic wound. These observations and interviews highlight a lack of proper implementation and understanding of EBP protocols among the staff.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to hospitalization. The resident was admitted with osteomyelitis and pressure ulcers on the right hip and sacral region. The facility did not follow the prescribed wound care orders, resulting in a malfunctioning wound vacuum-assisted closure (VAC) that was not addressed for several days. The resident's family and a confidential informant reported that the wound care was not being performed as ordered, and the resident was eventually hospitalized with MRSA septicemia and worsened pressure ulcers. Interviews with facility staff revealed a lack of training and knowledge regarding the use of wound VACs. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both confirmed that the staff were not trained to use the wound VAC and were uncomfortable with its operation. The DON was unaware of the issues with the wound VAC and the missed wound care treatments, which were not documented or reported to the physician as expected. The facility's policy on skin monitoring and management of pressure ulcers was not followed, as the resident did not receive the necessary treatment and services to promote healing and prevent infection. The Treatment Administration Record (TAR) showed multiple instances where wound care was not documented as done, and alternative wet-to-dry dressings were not applied when the wound VAC was not functioning. This lack of adherence to the care plan and facility policy contributed to the resident's deteriorating condition and subsequent hospitalization.
Failure to Provide Supervision for At-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and assistance for a resident identified as R1, who was at risk for falls due to a history of traumatic brain injury, cognitive deficits, and impulsive behavior. Despite having a care plan that acknowledged these risks, the facility did not implement any interventions for supervision. Between April 24, 2024, and May 15, 2024, R1 experienced nine unwitnessed falls, one of which resulted in injuries requiring medical treatment. The facility's incident and accident reports, as well as post-fall evaluations, did not reflect any changes or additions to R1's care plan to address the need for supervision. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that there was no documentation of any care plan to supervise R1 when he was awake, nor was there any interdisciplinary review or investigation into R1's status prior to each fall. The lack of supervision and failure to update the care plan after multiple falls led to R1 sustaining injuries, including a skin tear that developed into cellulitis and required surgical intervention. The facility's inaction in addressing R1's supervision needs contributed to the repeated falls and subsequent injuries.
Inadequate Monitoring of Tube Feeding Leads to Resident's Death
Penalty
Summary
The facility failed to provide adequate care for a resident who required tube feeding, resulting in a critical incident. The resident, who had a history of traumatic brain injury, mild neurocognitive disorder, severe protein-calorie malnutrition, PTSD, and repeated falls, was admitted with a feeding tube following hospital treatment for septic olecranon bursitis and a urinary tract infection. On the day of the incident, the resident was found unresponsive with irregular breathing while lying flat, despite the requirement for head elevation at 30 degrees during tube feeding. The resident was transported to the hospital, where he was pronounced dead upon arrival. Interviews and record reviews revealed that the nursing staff failed to monitor the resident adequately. LPN T found the resident lying flat with the tube feeding running and noted that the resident was known to slide down in bed. LPN B, who administered medications earlier, did not document the resident's condition or recall the last time she checked on him. The Assistant Director of Nursing and the Director of Nursing were unaware of the resident's tendency to slide down in bed, and there was no documentation of care provided between 6:00 PM and 10:00 PM when the resident was found in distress.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure an effective process for receiving and addressing grievances, as evidenced by the case of a resident who was sent to the facility for care of her pressure ulcers. The resident experienced a malfunction with the wound vacuum-assisted closure (wound vac) for at least three days and did not receive any other wound care during this period. This resulted in the resident being hospitalized. The resident's family member reported these concerns and filled out a grievance form on her behalf, as she was not feeling well enough to write herself. The grievance included issues with pain management, lack of assistance with care, and a nurse's inappropriate behavior. Despite the grievance being submitted, the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing reported not receiving any grievance forms from the resident and were unaware of her concerns. The facility's policy on grievances, last updated in 2019, outlines that grievances can be presented orally or in writing to the Administrator and should be addressed within three to seven days. However, in this case, the grievance process was not effectively followed, leading to unresolved concerns for the resident.
Failure to Follow Physician Orders for Diabetic Resident
Penalty
Summary
The facility failed to follow physician orders for a resident with diabetes, resulting in the resident not receiving medications as prescribed and the physician not being notified of high blood sugar readings. The resident, who had cognitive impairments, was supposed to receive Novolog insulin before meals and at bedtime, with specific instructions to administer 12 units of insulin and notify the physician if blood sugar levels exceeded 349. However, documentation showed that on multiple occasions, the resident's blood sugar was recorded as 'HI' (above the maximum range), and the appropriate actions were not taken. On one occasion, a nurse documented administering only 1 unit of insulin instead of the prescribed 12 units for a high blood sugar reading, and there was no evidence that the physician was notified. The Director of Nursing acknowledged the discrepancy and noted that the nurse involved was no longer employed at the facility, making it difficult to verify if the documentation was a typo. Additionally, the facility could not provide documentation that the physician was informed of the high blood sugar readings, despite the nurse's notes indicating that a message was logged for the physician. This failure to adhere to physician orders and ensure proper communication with the physician was identified during the survey.
Inadequate Nursing Competency for Wound Care
Penalty
Summary
The facility failed to ensure that nursing staff had the necessary competencies to provide adequate care for a resident with pressure ulcers requiring a wound vac. The resident was admitted to the facility for the care of her pressure ulcers, but the wound vac malfunctioned for at least three days, during which no wound care was provided. Family members and a confidential informant reported that the nursing staff did not know how to use the wound vac, resulting in missed treatments and inadequate care. The resident was eventually hospitalized due to the lack of proper wound care. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility had not provided training on the use of wound vacs to the nursing staff. The ADON confirmed that the staff was not comfortable using the wound vac, and the DON was unaware of any training provided before or after the resident's admission. The DON also acknowledged that there was no documentation of missed treatments or physician notifications, and the floor nursing staff had not received education on skin management. The Medication/Treatment Administration Record (MAR/TAR) showed several missed wound vac and pressure ulcer dressing treatments in July and August.
Deficient Nurse Call System
Penalty
Summary
The facility failed to ensure that residents had a functional nurse call system at all times, which resulted in the potential for serious psychosocial or physical harm. The facility's policy required that call lights be checked daily and any defects reported immediately for repair. However, observations revealed that the call light in a specific room's bathroom was hanging loosely from the wall and did not trigger a sound when tested. Interviews with staff confirmed that the call light system often malfunctioned, and the facility used a wireless cell phone connection that frequently lost signal, leading to delays in responding to residents' calls for assistance. Certified Nursing Assistants (CNAs) and Registered Nurses (RNs) reported ongoing issues with the call light system, including broken or missing cell phones, weak internet connections, and the need to share phones among staff. This situation forced staff to walk to a central area to check for activated call lights, which further delayed response times. Staff also mentioned that residents frequently complained about long wait times for assistance, and the facility was aware of these issues for several months but had not resolved them. The Maintenance Director reported being unable to access the call light program due to a locked-out computerized system, preventing proper audits and checks. Additionally, the call light in the observed room had been taped to the wall without a work order being submitted for repair. Interviews with various staff members, including CNAs, LPNs, and activity aides, consistently highlighted the malfunctioning call light system and the resulting frustration and delays in providing care to residents.
Staffing Deficiency Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of residents, resulting in long call light wait times, residents being left wet and/or soiled for extended periods, missed showers/baths, late medications, and staff burnout. This deficiency was observed in five residents who reported and demonstrated significant delays in receiving care. For instance, one resident reported waiting up to six hours to have his brief changed and being left on the commode for hours, causing discomfort and fear of staff retaliation if he asked for help during busy times. Another resident reported waiting over two hours for incontinence care, leading to soreness and burning sensations due to prolonged exposure to wet briefs. The deficiency was further corroborated by staff interviews and observations. Licensed Practical Nurses and Certified Nursing Assistants reported being overwhelmed due to low staffing levels, leading to missed care tasks such as scheduled showers and timely medication administration. Staff also reported not receiving lunch breaks and struggling to complete two-person transfers, which compromised resident safety. Observations confirmed that residents were left in soiled briefs for extended periods, and staff were visibly frustrated and unable to provide timely care due to being short-handed. The facility's staffing issues were also highlighted by the Employee Scheduler, who admitted that call-ins and unfilled shifts were common, and agency staff were not used unless multiple positions were open. This led to a situation where residents' basic care needs were not met, and staff were frequently pulled from their regular duties to cover for absent colleagues. The facility's policy on staffing, which mandates adequate staffing to meet resident needs, was not adhered to, resulting in significant care deficiencies and resident dissatisfaction.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete annual performance reviews for five Certified Nursing Assistants (CNAs) who had been employed for more than 12 months. This deficiency was identified through interviews and record reviews, which revealed that CNAs T, U, V, S, and XX did not have annual performance reviews in their personnel files for the past 12 months. The Regional Human Resources Director confirmed that the previous owners had relied solely on competency training and had not conducted annual performance evaluations for these CNAs. The facility's policy on annual performance evaluations, dated 5/1/24, mandates that all employees receive an annual evaluation to identify any deficiencies in their performance and to develop a plan for continued improvement. The lack of annual performance reviews for these CNAs resulted in the potential for unidentified performance concerns and unmet care needs. This deficiency was corroborated by the facility's own policy and external guidelines, which emphasize the importance of performance reviews in ensuring staff competency and improving overall patient care.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program, as evidenced by multiple observations of inadequate cleanliness and improper infection control practices. Shared equipment such as vitals machines, scales, and lifts were found to be visibly soiled with dust, debris, and dried substances. Housekeeping staff reported that they typically do not move resident personal hygiene items unless asked, and nursing staff indicated that sanitizing wipes were not always readily available, leading to inconsistent cleaning of shared equipment. In several instances, staff did not follow proper hand hygiene and glove use protocols during incontinence care. For example, two CNAs provided incontinence care to a resident without changing gloves between tasks, handling the resident, bedding, and other surfaces with soiled gloves. Another CNA failed to clean a resident's peri-area properly and used the same gloves to handle clean and soiled items. These actions were contrary to the facility's hand hygiene policy, which emphasizes the importance of hand hygiene in preventing the spread of infection. Interviews with staff revealed that the facility had recently noticed an increase in urinary tract infections and changes in residents' continence status. However, no audits or bedside observations had been conducted to address these concerns. The Infection Preventionist was still completing her certification course and was only partially fulfilling her role, while the Regional Director of Clinical Services and a Regional Nurse Consultant, who was not a certified Infection Preventionist, were assisting with infection control tasks. This lack of consistent and effective infection control oversight contributed to the deficiencies observed.
Failure to Ensure Timely Vaccination for Residents
Penalty
Summary
The facility failed to ensure that residents eligible for recommended vaccines were offered vaccination in a timely manner. This deficiency was identified for five residents who were reviewed for immunizations. Interviews with staff revealed that there was confusion and lack of clarity regarding who was responsible for tracking and ensuring that resident immunizations were up to date. The Registered Nurse transitioning into the Infection Preventionist (IP) position was still completing her certification course and was only partially handling the responsibilities. The Interim Director of Nursing (DON) reported pulling reports from the Michigan vaccine registry upon admission but was unaware of who was responsible for ensuring that resident immunizations were current. The Regional Director of Clinical Services/Infection Preventionist also indicated that the facility had just started to look at resident immunizations and was unsure of the current status. Record reviews revealed that none of the five residents had documentation of pneumococcal and/or influenza vaccines, nor were there any consents or declinations recorded. The facility's policy on pneumococcal immunizations stated that all residents should be assessed for eligibility and offered the vaccines upon admission unless medically contraindicated or previously vaccinated. However, this policy was not being followed, as evidenced by the lack of documentation and follow-through. The Infection Preventionist confirmed that immunizations were supposed to be part of the admission/nursing assessment but acknowledged that this was not being adhered to at the time, resulting in multiple resident immunizations not being in compliance with regulations.
Failure to Document and Offer COVID-19 Vaccinations
Penalty
Summary
The facility failed to ensure residents' medical records included documentation that residents or their representatives were educated, offered, and/or received the COVID-19 immunization as recommended by the CDC. This deficiency was identified for five residents who did not have proper documentation of being offered a booster shot, nor were there consents or declinations recorded. The residents involved had varying histories of COVID-19 vaccinations, but none had records indicating they were offered the booster doses as per CDC guidelines. Interviews with facility staff revealed a lack of clarity and responsibility regarding the tracking and updating of resident immunizations. The Registered Nurse transitioning into the Infection Preventionist role was still completing her certification and was only partially fulfilling the role. The Interim DON was responsible for pulling reports from the Michigan vaccine registry but did not know who was responsible for ensuring resident immunizations were up to date. The Regional Director of Clinical Services/Infection Preventionist admitted that the facility had just started looking at resident immunizations and was unsure of the current status. The facility's policy on COVID-19 vaccinations was not being followed, leading to multiple residents not being in compliance with immunization regulations.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, affecting 81 residents. During an environmental tour of the facility's laundry service, it was observed that nine out of eighteen overhead fluorescent light bulbs in the clean laundry room were non-functional. The return-air-exhaust ventilation grill was heavily soiled with dust and dirt deposits, and the flooring surface was soiled with accumulated and encrusted dust and dirt deposits. Similar conditions were noted in the soiled laundry room. The Director of Environmental Services indicated that staff would thoroughly clean all surfaces as soon as possible. In a common area environmental tour, several issues were noted, including soiled return-air-exhaust ventilation grills, missing countertop laminate edges, non-functional light assemblies, and soiled flooring surfaces. Specific areas affected included the visitor restroom, soiled utility room, janitor closet, shower/bathroom, nourishment room, tub room, nurses station, resident restrooms, activity room, basic nourishment room, main lobby, clean linen storage closet, and various resident rooms. Additionally, the atmospheric vacuum breaker was missing on some shower wand assemblies, and the commode base caulking in several restrooms was etched, scored, stained, and particulate. Interviews and record reviews revealed that the facility had a preventative maintenance program in place, but it was not effectively implemented. The Maintenance Director stated that the facility had only been using the TELS software system for about two months, and no specific entries related to the aforementioned maintenance concerns were found in the work orders for the last 60 days. Housekeeping staff reported that resident rooms and common areas should be cleaned daily, but the observed conditions indicated that this was not being done properly. The facility's policies and procedures for maintaining a safe and sanitary environment were not being followed, leading to the observed deficiencies.
Failure to Maintain Dignified Existence for Residents
Penalty
Summary
The facility failed to maintain a dignified existence for three residents, resulting in long call light wait times, residents being left wet and soiled, and feelings of frustration, anxiety, and embarrassment. Resident #81, who was cognitively intact, reported waiting up to 2 hours for assistance to use the bathroom, leading to unsafe situations where her significant other had to help her. Certified Nursing Assistants (CNAs) confirmed the long wait times and expressed awareness of the residents' frustrations. Resident #81 felt anxious and frustrated due to the long waits and the risk of incontinence episodes. Resident #9, who was cognitively impaired, reported waiting up to 6 hours to have his brief changed, especially during shift changes or meal times. He expressed fear of bothering the CNAs and being left on the commode for hours. Observations confirmed that Resident #9's call light was not promptly answered, and his brief was heavily saturated with urine when finally changed. The resident expressed appreciation for the assistance but noted that CNAs often did not have time to attend to his needs promptly. Resident #10, who was cognitively intact, reported frequent complaints from staff about being short-handed, particularly during night hours. She experienced long wait times to have her incontinence brief changed, leading to soreness and discomfort. Resident #10 reported waiting from 5:20 AM to 8:00 AM for her call light to be answered, during which time she remained in a wet brief. The resident noted that CNAs often did not carry call light phones, resulting in delayed responses to call lights.
Failure to Issue Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) for Medicare Part A services to three residents, resulting in the potential for these residents or their representatives to be unaware of changes in financial liability and delaying their ability to file an appeal. The deficiency was identified through interviews and record reviews, which revealed that the facility did not provide the required NOMNC forms to the residents before their discharge, despite their Medicare-covered stays ending on specific dates. The residents involved were Resident #89, #90, and #91, all of whom were discharged to home after completing their rehabilitation goals. Resident #89 was admitted with Medicare Part A as the primary payer and discharged on 3/21/24. The facility's records indicated that the last covered day of Part A service was 3/20/24, but no NOMNC form was provided. Similarly, Resident #90, admitted with Medicare Part A, was discharged on 3/7/24, with the last covered day of Part A service being 3/6/24, yet no NOMNC form was issued. Resident #91, also admitted with Medicare Part A, was discharged on 3/8/24, with the last covered day of Part A service being 3/7/24, and again, no NOMNC form was provided. Interviews with the Rehab Director and the Business Office Manager confirmed that the residents met their rehabilitation goals before discharge. However, the Business Office Manager admitted that the facility only issues NOMNC forms to residents who discharge from therapy services but remain in the facility, not to those who are discharged home. This practice led to the failure to provide the necessary NOMNC forms to the three residents, resulting in the identified deficiency.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in potential harm. Resident #11, diagnosed with Alzheimer's disease, depression, and anxiety, had a care plan that included fall precautions such as wearing gripper socks and having a fall mat in place. However, observations revealed that Resident #11 was not wearing gripper socks and the fall mat was not positioned correctly, increasing the risk of falls. Interviews with staff confirmed that these precautions were not consistently followed, despite the resident's high fall risk and severe cognitive impairment. Resident #13, who was cognitively intact and had a history of trauma from a recent fire, did not have a care plan addressing her trauma-related needs. Despite documented symptoms of depression, anxiety, and hallucinations related to the fire, the care plan lacked specific interventions to manage these issues. Interviews with the resident and social services staff highlighted the resident's ongoing distress and the need for trauma-informed care, which was not reflected in her care plan. The deficiencies in care planning for both residents were identified through observations, interviews, and record reviews. The facility's failure to implement and update care plans according to the residents' needs and conditions resulted in inadequate care and potential harm. The care plans did not include measurable objectives, time frames, or specific interventions to address the residents' physical, mental, and psychosocial well-being, as required by regulatory standards.
Latest citations in Michigan
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
