Avista Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Saginaw, Michigan.
- Location
- 2901 Galaxy Drive, Saginaw, Michigan 48601
- CMS Provider Number
- 235139
- Inspections on file
- 22
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Avista Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with a history of CVA with left hemiplegia, orthostatic hypotension, and multiple cardiac and metabolic comorbidities experienced a fall in the weight room while being assisted off a standing scale by a CNA. The incident report documented that the resident lost footing on the scale and was found alert and oriented with no injuries noted, but did not include information about footwear or any witness statements. The DON later stated she only spoke with the nurse, did not interview the CNA or the resident, and did not obtain written statements, while indicating the facility followed the existing plan of care. The resident’s fall care plan, which already addressed recurrent falls and related conditions, was not updated with the intervention to use a seated scale for weights until four days after the fall, demonstrating a failure to timely revise the fall care plan based on the incident.
A resident with left hemiplegia, foot drop, orthostatic hypotension, and a history of falls was awakened in the early morning by a CNA, at an LPN’s direction, to obtain a weight. Despite care plan and therapy documentation that the resident required a left AFO and a gait belt to stand, the CNA transferred the resident barefoot and without the AFO or gait belt to a wheelchair platform scale in a small weight room with only one handrail. The resident was stood on the scale, began to black out, and fell backward to the floor, later reporting left leg and knee pain and bleeding from the left great toe. The CNA acknowledged not using the AFO or gait belt and that the resident had no socks on, while the LPN reported believing the resident had gripper socks and documented that he lost his footing on the scale. The DON stated she did not interview the CNA or the resident and obtained no witness statements, relying only on the nurse’s account, despite the facility’s fall policy requiring identification of interventions based on resident-specific risks.
Surveyors observed multiple deficiencies in the kitchen, including dirty and damaged food service equipment, improperly cleaned trays and plate warmers, and unsanitary storage conditions in the walk-in cooler and freezer. Wet and soiled items were found among clean supplies, and significant ice buildup in the freezer led to improper door closure and water accumulation, with staff acknowledging the ongoing issue.
Surveyors found that medications, including multi-dose inhalers, insulin pens, and ophthalmic drops, were stored in medication carts without required open or expiration dates, and some medications belonged to discharged residents. Nursing staff acknowledged the lack of proper dating and uncertainty about policy requirements, and loose, unidentified tablets were also found in the carts. These practices did not follow the facility's policies for medication storage and labeling.
Surveyors observed multiple infection control breaches, including a kitchen staff member with exposed hair and artificial nails, an LPN failing to use proper barrier precautions and hand hygiene during wound care for two residents, and a resident on contact precautions left with soiled linen in the room and no accessible soap for hand hygiene. These actions were not in compliance with facility policy and infection prevention standards.
Two residents did not receive timely wound care as ordered, with wound dressings remaining unchanged for multiple days despite documentation indicating daily treatments were completed. Staff interviews and record reviews revealed discrepancies between treatment records and actual care provided, resulting in missed wound care for residents with complex medical conditions.
Surveyors identified that the facility failed to implement and monitor pressure ulcer prevention measures for two residents. One resident developed a facility-acquired penile erosion due to improper urinary catheter management, with observations noting taut tubing and resident-reported pain. Another resident, dependent on staff for care, was found with a non-functional air mattress due to a bent plug, and there was no documentation or process in place for staff to check the mattress settings. These deficiencies were confirmed through observation, interviews, and record review.
A resident with multiple medical conditions, including dementia and diabetes, was observed multiple times with her trapeze device for bed mobility out of reach, despite her care plan indicating its use. Staff were unsure if the device had been repositioned during care and not returned to an accessible position, resulting in the resident being unable to access the assistive device as needed.
A resident with chronic respiratory conditions was observed to have their nebulizer mask left out on a plastic bag and later stored in a nightstand drawer, rather than in a storage bag as required by facility policy. Staff interviews confirmed the mask should have been bagged after drying, but this was not done following multiple treatments.
Surveyors observed that the facility installed a deep-fat fryer next to a new gas stove without the required baffle plate, had a shelf protruding over stove burners, failed to ensure appliances were returned to approved locations, and did not re-evaluate the kitchen fire suppression system after equipment changes, all in violation of NFPA 96 standards.
The facility did not provide documentation showing that semiannual visual inspections of fire alarm initiating devices were completed as required by NFPA 72. This was confirmed during interviews with the Maintenance Director and Regional Director.
A quarterly inspection revealed a water flow switch failure in the facility's sprinkler suppression system, and the facility did not provide documentation that this deficiency was corrected as required by NFPA standards. This was confirmed during record review and interviews with facility leadership.
Surveyors found that cross corridor smoke barrier doors near two resident rooms did not close properly when tested, failing to prevent the passage of smoke as required by NFPA 101. This deficiency was confirmed with the Maintenance Director and could affect about 25 occupants during a fire emergency.
The facility failed to maintain safe cold holding temperatures for milk, with observations showing milk temperatures exceeding the safe limit of 41°F. The Dietary Manager confirmed that the cooler was left open during meal service, contributing to the issue. Temperature logs were incomplete and did not routinely check serving temperatures, leading to multiple instances of milk being served at unsafe temperatures.
The facility did not adequately address or document responses to grievances reported during Resident Council meetings, affecting residents' quality of life. Residents expressed that their concerns were not followed up on, and a review of notes from June 2023 to May 2024 showed a lack of documentation of responses to specific issues. The facility's policy requires written responses to grievances, but the Activities Director confirmed no documentation of follow-up. Grievances included issues with food, therapy, nursing, social services, housekeeping, and maintenance.
The facility failed to honor residents' food choices and maintain food palatability and temperature, leading to dissatisfaction and hunger. A resident reported receiving disliked food items and inadequate portions, while a Resident Council meeting highlighted issues with meal timeliness, flavor, and temperature. Observations confirmed missing condiments and improperly chilled beverages.
A facility failed to assess and document a resident's incompetency before enacting a Durable Power of Attorney (DPOA), leading to medical decisions being made without legal documentation. The resident, with severe cognitive impairment, had discrepancies in advance directive documentation and informed consent for psychoactive medications. The facility's policy was not provided by the survey's conclusion.
The facility failed to provide adequate hygiene care and documentation for two residents. A female resident with severe cognitive impairment was observed with long facial hair, despite documentation indicating completed personal hygiene tasks. Staff interviews revealed a lack of specific documentation for female shaving refusals. Another resident, dependent on staff for daily living activities, was observed in bed for an extended period, contrary to their care plan. The Director of Nursing acknowledged these issues.
The facility failed to implement a comprehensive Restorative Nursing program to maintain or improve Range of Motion (ROM) for two residents, resulting in a lack of ongoing and accurate assessment and documentation of ROM and contractures. One resident with severe vascular dementia and right-sided hemiplegia had no care plan for Restorative Nursing or ROM exercises, while another resident with anoxic brain damage and impaired ROM had multiple unused splints and braces. Interviews revealed the facility was developing a Restorative Nursing Program but had not yet implemented it.
A resident suffered a fractured tibia and fibula after sliding out of their wheelchair during transport due to a faulty seat belt in a facility van. The transport staff, a recently transitioned CNA, lacked adequate training in securing residents. The facility failed to conduct a thorough investigation or report the incident, and discrepancies were found in staff accounts of the event.
A facility failed to provide proper catheter care and complete UTI treatment for two residents. One resident's catheter was unsanitary and not secured, while another experienced a delay in receiving prescribed antibiotics for a UTI, receiving only 17 of 18 doses. The facility lacked documentation of peri-care audits, indicating deficiencies in infection control practices.
A resident with a PICC line did not receive timely dressing changes as required by facility policy and healthcare provider orders, leading to concerns about care and potential infection risk. The resident's dressing was outdated, and an LPN failed to address this during an IV infusion check. The MAR inaccurately recorded a dressing change, and during an observed dressing change, the ADON compromised sterile technique. The DON confirmed the discrepancies and acknowledged the need for corrective action.
Failure to Timely Update Fall Care Plan After Weight-Room Fall
Penalty
Summary
The deficiency involves the facility’s failure to timely follow and update a fall care plan for one resident after a fall event, resulting in missed interventions not being incorporated into the care plan. On 4/2/2026 at 6:00 AM, a fall incident report documented that a CNA requested nursing assistance in the weight room across from the therapy office, where the resident was found alert and oriented, sitting against the wall. The CNA reported that the resident lost his footing on the weight scale as he was being assisted back to his wheelchair and stated the resident did not hit his head. The nurse’s assessment noted no bruising or injuries, and the resident reported he lost his step on his weaker side as the aide assisted him back into the wheelchair. The incident report did not mention the resident’s footwear at the time of the fall and indicated that no witness statements were obtained. The resident’s medical record showed admission from a hospital with multiple diagnoses, including heart disease, right carotid artery occlusion and stenosis, hemiplegia and hemiparesis post intracerebral hemorrhage affecting the left non-dominant side, diabetes, depression, anxiety disorder, hypothyroidism, orthostatic hypotension, anemia, moderate protein-calorie malnutrition, mitral and tricuspid valve insufficiency, and cardiomyopathy. The care plan documented that the resident required one-person assistance with ambulation using a 2-wheeled walker and left foot orthosis, and assistance with transfers, allowing increased time due to dizziness. A fall care plan dated 3/3/2026 addressed recurrent falls and related conditions, with interventions such as transferring and changing positions slowly and placing the left side of the bed against the wall. However, the intervention to use a seated scale when obtaining weights was not added until 4/6/2026, four days after the fall. In an interview, the DON stated she spoke only with the nurse, did not obtain notes or witness statements, and did not interview the CNA or the resident, while asserting that the facility followed the plan of care. The only care plan policy provided addressed baseline care plans within 48 hours of admission and did not address the timeliness of updating comprehensive care plans after incidents.
Failure to Use AFO and Gait Belt During Early-Morning Weighing Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to prevent a fall and ensure that a resident’s prescribed left foot Ankle Foot Orthosis (AFO) and a gait belt were applied prior to standing the resident for a weight measurement. On the date of the incident at approximately 4:00–6:00 AM, a CNA, at the direction of an LPN, woke the resident to obtain a weight, despite the resident stating he was tired and did not want to get up. The resident reported that he needed to sit for about 10 minutes before standing due to blood pressure concerns, but he was transferred from bed to a wheelchair and then taken to a weight room across from the therapy office. The CNA later stated this was the first resident weight she had obtained since being hired and that she worked the night shift. Record review showed that the resident had multiple medical diagnoses, including hemiplegia and hemiparesis affecting the left non-dominant side after an intracerebral hemorrhage, orthostatic hypotension, diabetes, anemia, heart disease, and a history of left hip fracture. The resident’s care plan documented that he required assistance from one staff member for ambulation with a two-wheeled walker and left foot AFO, and that he received physical therapy for gait training and neuromuscular re-education. Therapy staff documented that the resident had left foot drop and required the left leg AFO and a gait belt to stand. The fall care plan identified recurrent falls and conditions such as CVA with left hemiplegia, dizziness, fatigue, and orthostatic hypotension, with interventions including transferring and changing positions slowly. During the incident, the CNA took the resident, who was barefoot and without his AFO or a gait belt, to a wheelchair platform scale in a small weight room that had only one handrail on the back of the scale. The CNA had the resident stand on the scale, and he began to fall backwards against the wall. The CNA was unable to lift him and left to get the LPN. When the nurse arrived, the resident was on the floor. The nurse’s incident report documented that the resident lost his footing on the weight scale as he was being assisted back to his wheelchair, and that no injuries were noted at that time. The resident later reported that he started to black out, fell backwards, landed on his left foot/leg, hurt his knee, and that his left big toe was bleeding. The DON stated that she did not interview the CNA or the resident and that no witness statements were obtained, and she characterized the follow-up as not a “huge investigation,” relying only on speaking with the nurse and reviewing the plan of care. Further interviews and record reviews confirmed that the resident typically used a seated chair scale located elsewhere on the unit and that, according to the resident, staff usually weighed him using that chair scale or by subtracting the wheelchair weight. The CNA acknowledged that the resident was barefoot and that she did not apply his leg splint (AFO) or use a gait belt when standing him on the scale. The LPN stated that the resident needed daily weights and that she had explained to him the severity of not getting weighed, and she believed he had yellow gripper socks on, although the CNA and resident reported he was barefoot. The facility’s fall policy stated that staff would identify interventions related to residents’ specific risks and causes to try to prevent falls and minimize complications, and defined a fall as unintentionally coming to rest on the ground, floor, or other lower level. The resident’s left knee x-ray obtained two days later documented mild osteoarthritis with clinical information of pain. The DON reported that residents were not typically awakened at that early hour solely for weights and that she believed weights could be done at any time during the day shift. However, the resident’s weight log showed a standing weight recorded shortly before 6:00 AM on the date of the incident. The DON also stated that she did not speak with the CNA or the resident about the fall and that no witness statements were collected. The lack of use of the resident’s prescribed AFO and gait belt, the decision to obtain a standing weight on a platform scale in a room with limited support surfaces, and the incomplete investigation and documentation of the event were all identified as contributing factors to the fall and the failure to ensure the area was free from accident hazards and that adequate supervision and assistive devices were used to prevent accidents.
Failure to Maintain Sanitary Food Service Equipment and Storage Areas
Penalty
Summary
The facility failed to maintain food service equipment and ensure sanitary conditions in the kitchen, as observed during a kitchen tour. Specific deficiencies included a refrigerator with a ripped door seal and food particles in the door corner, as well as streaks and smears on the exterior that were easily removed when wiped. Seven meal trays used for serving residents had jagged edges, and four plate warmers that were supposed to be clean had dried food particles. Five steam table lids had bent corners and dried food residue. The garbage can lid had a white substance, and a rack with clean, ready-to-use pans and lids was found with wet and dirty items. Additionally, a trolley in the back kitchen hallway had a resident's used meal tray and an unknown pink substance on its exterior, contrary to staff procedures for tray placement. Further issues were identified in the walk-in cooler and freezer. The cooler had a trail of water leading into the freezer, and the freezer itself had thick snow and ice buildup on the door frame, ceiling, and above the fan, which prevented the door from closing properly. There was condensation and ice on the plastic curtains and door frame, and during a delivery, boxes were observed with wet marks from ceiling drips. The freezer floor was visibly wet, with water tracking back into the cooler. The Maintenance Director acknowledged awareness of the ice and snow buildup, attributing it to dietary staff not closing the freezer door tightly. The facility's sanitization policy requires all equipment and utensils to be washed and sanitized, and for manually washed items to air dry whenever practical, which was not consistently followed.
Failure to Properly Store and Label Medications in Medication Carts
Penalty
Summary
Surveyors identified multiple failures in the facility's medication storage and labeling practices across all four medication carts reviewed. Observations revealed that multi-dose medications, such as inhalers, insulin pens, ophthalmic drops, and nasal sprays, were frequently found without required open dates or expiration dates. In several instances, medications belonging to residents who had been discharged remained in the carts, and loose, unidentified tablets were discovered in various drawers. These findings were corroborated by interviews with nursing staff, who acknowledged the lack of proper dating and, in some cases, uncertainty regarding the facility's policy on medication dating. Record reviews of the facility's 'Storage of Medications' and 'Medication Administration' policies indicated that medications and biologicals are to be stored securely and dated upon opening, with certain medications requiring a shorter expiration period once opened. Despite these policies, surveyors observed opened containers of blood sugar testing strips, insulin pens, and other multi-dose medications without any indication of when they were opened or when they should be discarded. Staff interviews confirmed that these items were in use without adherence to the documented procedures for dating and discarding. The deficiency was further evidenced by the presence of medications for residents no longer residing in the facility, as well as loose tablets found in medication carts without identification or proper storage. Staff members, including RNs and LPNs, were unable to provide consistent explanations for the lack of dating or the continued presence of medications for discharged residents. These actions and inactions directly contravened the facility's own policies and accepted professional standards for medication storage and labeling.
Infection Control Failures in Kitchen, Wound Care, and Isolation Precautions
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in several areas, as observed during the survey. In the kitchen, the Dietary Manager was seen wearing a hair net that did not fully cover her hair, with long tendrils exposed on both sides of her face, and was also found to have long artificial nails. Both of these actions were in direct violation of the facility's policy, which requires hair nets to fully cover hair and prohibits artificial nails for staff involved in food preparation. The Dietary Manager acknowledged awareness of these requirements during interviews, and the Infection Control Nurse and Director of Nursing confirmed that these practices were not in compliance with CDC recommendations and facility policy. During wound care observations, an LPN failed to use enhanced barrier precautions when assessing a resident's PEG tube site, not donning a gown or gloves before lifting the resident's shirt and breast to access the tube. In another instance, the same LPN and a CNA performed wound care on a different resident with open stage III pressure ulcers. After cleaning bowel material from the resident's buttock region, neither the LPN nor the CNA changed gloves before proceeding with wound care, and the LPN did not perform hand hygiene before donning new gloves. The LPN also reached into her uniform pocket with gloved hands to retrieve a pen, further increasing the risk of cross-contamination during the dressing change. Additionally, a resident on contact precautions for C. difficile was found in a room with a pile of soiled linen, including sheets and blankets with dried red substances, left atop a recliner. The resident reported the linen had been changed that morning, but it had not been removed from the room. The soap dispenser in the room was also found to be non-functional, as the soap bag was not properly engaged, making hand hygiene inaccessible for staff and visitors. The Infection Control Nurse confirmed both the improper storage of soiled linen and the lack of accessible soap in the resident's room.
Failure to Provide Timely and Documented Wound Care
Penalty
Summary
The facility failed to assess, monitor, and document wound care in a timely manner for two residents, resulting in missed treatments. For one resident, an occlusive dressing on the left elbow was observed to be dated several days prior, despite treatment administration records indicating that daily wound care had been completed. Interviews revealed that the nurses who signed off on the treatments were not the ones who actually performed them, and the old dressing remained in place, indicating that the required wound care was not provided as documented. The resident had diagnoses including aphasia, hypertension, and stroke, and required assistance with activities of daily living. For another resident, a wound dressing on the right foot was found to be dated two days prior, even though physician orders required daily dressing changes. The resident had a complex medical history including sepsis, diabetes, atrial fibrillation, Guillain-Barre Syndrome, Bell's Palsy, and borderline personality disorder. The discrepancy in dressing dates and documentation suggested that at least one daily wound care treatment was missed, despite staff initially believing the dressing was dated incorrectly.
Failure to Implement and Monitor Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement preventive pressure ulcer measures and prevent new ulcers from developing for two residents. For one resident with a urinary catheter, observations revealed a left-sided penile erosion measuring 3 to 3.5 cm in length, attributed to the catheter. The catheter tubing was noted to be taut from the penis head to the left thigh, and the resident reported pain at the site. The resident also stated that the leg bag would become heavy and pull on the tubing, causing discomfort. During the observation, the LPN did not use hand sanitizer before donning gloves and had long artificial nails with jewelry attachments. The wound was confirmed to be facility-acquired, and the wound care nurse acknowledged the difficulty in measuring the wound accurately due to its location and the limitations of photographic documentation. The DON confirmed the erosion was caused by the catheter and was being treated in-house. For another resident, the facility failed to ensure the proper functioning of a prescribed air mattress intended to prevent pressure ulcers. The resident, who was dependent on staff for activities of daily living and had multiple comorbidities including diabetes, stroke, and muscle weakness, was observed in bed with an air mattress that was not plugged in and not functioning as intended. The plug was found to have a bent prong, preventing it from being plugged in. There was no documentation in the physician's orders or care records requiring staff to check the air mattress for functionality or to ensure it was set to the correct alternative pressure setting. Staff interviews confirmed that there was no established process for documenting checks of the air mattress prior to the surveyor's intervention. These deficiencies were identified through direct observation, staff and resident interviews, and record reviews. The lack of preventive measures and monitoring contributed to the development of a facility-acquired pressure injury in one resident and the risk of pressure ulcer development in another, both of whom were dependent on staff for care and at high risk for skin breakdown.
Trapeze Device Not Accessible for Bed Mobility
Penalty
Summary
A deficiency was identified when a resident's trapeze, an assistive device for bed mobility, was not accessible on multiple occasions. Observations showed that the trapeze was flipped over the stabilization bar and out of the resident's reach while she was in bed. When asked, the resident confirmed she was unable to reach the device and demonstrated her inability to access it. The care plan indicated a preference for the trapeze to assist with bed mobility, and records confirmed the resident was assessed as safe to use it. Despite the care plan and assessment, the trapeze remained inaccessible during several observations, and staff were unsure if it had been repositioned during care and not returned to an accessible position. The resident's medical history included diabetes, dementia, atrial fibrillation, and hypertension. The deficiency was based on the failure to ensure the assistive device was within reach as required to maintain or improve the resident's range of motion and mobility.
Failure to Properly Store Nebulizer Mask After Use
Penalty
Summary
A deficiency was identified when a resident who required nebulizer treatments for chronic heart and lung disease did not have their nebulizer mask stored in accordance with facility policy. The resident, who had multiple diagnoses including chronic respiratory failure, Alzheimer's Disease, and required assistance with all activities of daily living, was observed to have their dry nebulizer mask left on top of a plastic bag next to the treatment machine, rather than being placed inside a storage bag as required. This observation was made several hours after the last documented treatment, indicating the mask had sufficient time to dry and be stored properly. A subsequent observation found the nebulizer mask and attached oxygen tubing stored inside a closed nightstand drawer, with the tubing hanging out, rather than in a designated storage bag. During interviews, the resident confirmed the timing of the last treatment, and the Clinical Nurse Manager acknowledged that nebulizer masks should be stored in a bag when not in use. These findings demonstrate that staff did not follow the facility's nebulizer process policy regarding the storage of respiratory equipment.
Noncompliance with NFPA 96 Standards for Kitchen Equipment Installation
Penalty
Summary
The facility failed to ensure that cooking facilities were installed and protected in accordance with NFPA 96 standards. Observations revealed that a newly installed deep-fat fryer was placed within 16 inches of the surface flame of a new six-burner gas stove, without the required steel or tempered glass baffle plate of at least 8 inches in height between the fryer and the stove. Additionally, a shelf was found protruding over the stove top burners, which could obstruct the hood suppression system as per NFPA 96 requirements. The facility also did not provide approved methods to ensure that cooking appliances are returned to their approved design locations. Further, after the installation of the new gas stove and the addition of the deep-fat fryer, the facility did not have the kitchen Ansul fire extinguishing system re-evaluated as required by NFPA 96. These deficiencies were confirmed through interviews with the Maintenance Director and Regional Director at the time of observation. No information about specific residents or their conditions was provided in the report.
Failure to Document Semiannual Fire Alarm System Inspections
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained according to an approved program in compliance with NFPA 72. During a record review, it was found that there was no documentation available to show that the required semiannual visual inspection of the fire alarm initiating devices had been completed, as specified by NFPA 72, section 14.3. This lack of documentation was confirmed during interviews with both the Maintenance Director and the Regional Director at the time of the survey. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Document Correction of Sprinkler System Water Flow Switch Deficiency
Penalty
Summary
The facility failed to provide documentation that a water flow switch deficiency, identified during a quarterly sprinkler inspection, had been corrected as required by NFPA 72, 17.12.2. During a review of facility records, it was found that the sprinkler suppression system inspection report indicated the water flow switch failed during testing, and there was no evidence that this issue had been addressed. This finding was confirmed through interviews with the Maintenance Director and Regional Director at the time of the record review. No information was provided regarding specific residents or their medical conditions in relation to this deficiency.
Failure to Maintain Smoke Barrier Door Functionality
Penalty
Summary
Surveyors observed that the facility failed to maintain the proper operation of smoke barrier doors in accordance with NFPA 101 requirements. Specifically, during an inspection, the cross corridor doors near resident rooms #205 and #208 did not close properly when tested, which would prevent them from stopping the passage of smoke as required. These deficiencies were confirmed through interviews with the Maintenance Director at the time of observation. Approximately 25 occupants could be affected by this failure in the event of a fire emergency, as the doors did not function as intended to provide a smoke barrier.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain appropriate cold holding temperatures for potentially hazardous food, specifically milk, in the kitchen, which increased the potential for foodborne illness among the 79 residents receiving meal services. During an observation, the surveyor noted that the two-door reach-in cooler was left open during meal service, which was confirmed by the Dietary Manager (DM) as a normal practice. The temperature of the milk was found to be 55 degrees Fahrenheit, exceeding the safe temperature limit of 41 degrees Fahrenheit as per the 2017 U.S. Public Health Service Food Code. The DM acknowledged that such milk would typically be discarded. Further observations revealed that milk served to residents in the dining room and on tray carts also exceeded safe temperature limits, with readings between 47.5 and 52.3 degrees Fahrenheit. The facility's temperature logs lacked documentation for certain days and did not include start or discard times for milk, nor did they routinely check serving temperatures. The logs showed multiple instances of milk being served at unsafe temperatures, ranging from 44 to 54 degrees Fahrenheit. The facility's Food Preparation and Service Policy emphasized maintaining potentially hazardous foods below 41 degrees Fahrenheit to prevent the growth of harmful pathogens, which was not adhered to in this case.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to adequately address and document responses to grievances reported during Resident Council meetings, affecting the quality of life for residents. During a Resident Council meeting, residents expressed that their concerns were not being followed up on or resolved, with staff only asking generalized questions about whether issues had been resolved. A review of Resident Council notes from June 2023 to May 2024 revealed that while residents voiced concerns, the notes did not specify issues with specific disciplines, nor was there documentation of responses to these concerns at subsequent meetings. The facility's policy on grievance procedures requires that all grievances, complaints, or recommendations from resident or family groups be considered and responded to in writing, including the rationale for the response. However, the Activities Director confirmed that there was no documentation of follow-up on resident concerns from Resident Council meetings. Specific grievances included issues with food palatability, therapy services, nursing care, social services, housekeeping, and maintenance, among others, with no documented resolutions or updates provided to the residents.
Deficiencies in Food Service and Resident Satisfaction
Penalty
Summary
The facility failed to ensure that residents' food choices were honored, food was palatable, and an adequate amount of food was offered. During a noon meal observation, residents were served chili and salad without the Texas toast that was listed on the menu. The Dietary Manager acknowledged that the toast was overlooked and mentioned that staffing issues have delayed the implementation of a system to take residents' meal preferences. Resident #47, who is alert and able to make healthcare decisions, reported receiving food items he disliked, such as oatmeal, and not being informed about alternative menu options. The resident also expressed dissatisfaction with the portion sizes and the temperature of the food. During a Resident Council meeting, attendees expressed concerns about the timeliness, flavor, and temperature of meals, as well as inconsistent portion sizes and accompaniments. An observation of a lunch meal revealed missing condiments and accompaniments, and the beverages were not served at a cold temperature. The Dietary Manager confirmed the issues with food temperature during subsequent observations. These deficiencies resulted in residents feeling anger, frustration, and hunger.
Failure to Ensure Proper Incompetency Assessment Before Enacting DPOA
Penalty
Summary
The facility failed to ensure proper assessment and documentation of incompetency before enacting a Durable Power of Attorney (DPOA) for a resident, leading to medical decisions being made without legal documentation of incompetency. Resident #28, who was admitted with diagnoses including dementia with behavioral disturbance, was found to have a DPOA enacted before a formal determination of incompetency by two physicians. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment, requiring supervision for Activities of Daily Living (ADL). The review of the resident's records revealed discrepancies in the documentation of advance directives and the signing of informed consent for psychoactive medications. The Advance Directives/Medical Treatment Decisions form was improperly completed, lacking the resident's signature and only signed by a facility LPN. Additionally, the Informed Consent for Psychoactive Medications form for Seroquel was signed by a family member before the resident was deemed incompetent. Interviews with the Social Services Director and the Administrator confirmed these findings, and the facility's policy/procedure was not provided by the conclusion of the survey.
Deficiencies in Hygiene Care and Documentation
Penalty
Summary
The facility failed to provide adequate hygiene care for two residents, resulting in deficiencies in personal grooming and documentation. Resident #28, a female with severe cognitive impairment and multiple health issues, was observed with long, visible facial hair on two separate occasions. Despite the documentation indicating that personal hygiene tasks were completed, the facial hair was not removed. Interviews with staff revealed that there was no specific area in the electronic medical record (EMR) to document the refusal of shaving for female residents, unlike for male residents. The Director of Nursing acknowledged the lack of documentation for refusals and the understanding of the issue. Resident #23, who is dependent on staff for all activities of daily living due to conditions such as stroke and dementia, was observed resting in bed for an extended period. Despite the care plan indicating the need for repositioning and activity out of bed, the resident remained in bed until the surveyor's inquiry prompted action. The Director of Nursing was informed of the situation, and the resident was later observed sitting comfortably in a reclining wheelchair. These observations highlight the facility's failure to ensure proper documentation and execution of care plans for residents requiring assistance with daily living activities.
Failure to Implement Restorative Nursing Program for ROM
Penalty
Summary
The facility failed to implement a comprehensive Restorative Nursing program to maintain or improve Range of Motion (ROM) for two residents, resulting in a lack of ongoing and accurate assessment and documentation of ROM and contractures. Resident #36, who has severe vascular dementia and right-sided hemiplegia, was observed with a bent right arm and fist, indicating contractures. Despite being at high risk for contracture development, there was no care plan in place for Restorative Nursing or ROM exercises, and no splints or braces were observed in the resident's room. Resident #44, with a history of anoxic brain damage and impaired ROM in both upper and lower extremities, was found to have multiple splints and braces piled on top of their closet, which were rarely used. The resident reported that staff no longer assisted with ROM exercises, and there was no current order for Restorative Nursing or ROM. The resident's care plan included discontinued interventions for passive ROM and brace use, and there was no documentation of current ROM assessments or therapy evaluations. Interviews with facility staff, including the Director of Nursing (DON), revealed that the facility was in the process of developing a Restorative Nursing Program but had not yet implemented it. The DON confirmed the presence of contractures in both residents but could not provide explanations for the lack of Restorative Nursing services or specific ROM exercises. The facility did not provide a policy or procedure for Restorative Nursing by the conclusion of the survey.
Inadequate Staff Training and Equipment Monitoring Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate staff training, equipment monitoring, and accident prevention, leading to a serious incident involving a resident. The resident, who was cognitively intact but required maximum assistance for daily activities, suffered a fractured tibia and fibula after sliding out of their wheelchair during transport in a facility van. The incident occurred because the seat belt securing the resident was not properly engaged, allowing the resident to fall and sustain injuries. The investigation revealed several deficiencies in the facility's procedures. The transport staff member, who had recently transitioned from a CNA role, did not receive adequate training or demonstrate competency in securing residents in the van. The seat belt in the van was faulty, as it clicked but did not securely latch, and this issue was not identified or addressed prior to the incident. Additionally, the facility did not conduct a thorough investigation or report the incident to the State Agency, and there was a lack of documentation regarding the training and competency of the transport staff. Interviews with the resident and staff highlighted discrepancies in the facility's account of the incident. The resident reported that their legs were caught under the chair during the fall, and they experienced significant pain and swelling upon returning to the facility. The facility's Administrator and DON were unable to provide consistent information about the incident, and there was no documentation of a comprehensive investigation or corrective actions taken to prevent future occurrences.
Deficiencies in Catheter Care and UTI Treatment
Penalty
Summary
The facility failed to ensure proper assessment, maintenance, and care of an indwelling urinary catheter for one resident and did not complete the treatment of a urinary tract infection (UTI) for another resident. For the resident with the indwelling urinary catheter, the catheter was observed to be maintained in an unsanitary manner, with the tubing soiled with a brown substance resembling bowel movement and not secured inside the securement device. The securement device itself was soiled and appeared old, indicating a lack of adherence to professional standards of practice for catheter care. Another resident experienced a delay and incomplete antibiotic therapy for a UTI. The resident was readmitted to the facility after a hospital discharge with a prescription for Cefpodoxime Proxetil to treat the UTI. However, the medication was not available upon the resident's return, and the first dose was not administered until two days later. The resident ultimately received only 17 out of the prescribed 18 doses. The facility's infection control audits revealed numerous and recurrent UTIs for this resident, yet there was no documentation of peri-care audits to ensure staff were performing perineal care correctly. The facility's Director of Nursing and Infection Control Nurse acknowledged the lack of documentation for peri-care audits and the delay in starting the prescribed antibiotic. The failure to secure the catheter properly and the delay in antibiotic administration highlight deficiencies in the facility's infection control practices and adherence to care protocols, potentially contributing to ongoing health issues for the residents involved.
Improper PICC Line Care and Documentation Issues
Penalty
Summary
The facility failed to provide appropriate care for a resident with a Peripherally Inserted Central Catheter (PICC line), as evidenced by the lack of timely dressing changes and improper sterile technique during a dressing change. The resident, who was cognitively intact and required assistance with activities of daily living, had a PICC line dressing dated 5/24/24, despite facility policy and healthcare provider orders requiring weekly changes. The resident expressed concerns about the lack of care, indicating they had informed the nursing staff about the overdue dressing change, which was not addressed. During an observation, a Licensed Practical Nurse (LPN) failed to address the outdated PICC line dressing while attending to a beeping IV infusion. The Medication Administration Record (MAR) inaccurately documented a dressing change on 6/2/24, which was contradicted by the actual dressing date. Furthermore, during a dressing change observed by the Assistant Director of Nursing (ADON), sterile technique was compromised when the ADON turned their back on the sterile field, allowing for potential contamination. The Director of Nursing (DON) confirmed the discrepancy in the dressing change records and acknowledged the need for corrective action.
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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.
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