Boulder Park Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlevoix, Michigan.
- Location
- 14676 West Upright, Charlevoix, Michigan 49720
- CMS Provider Number
- 235526
- Inspections on file
- 26
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Boulder Park Terrace during CMS and state inspections, most recent first.
The facility failed to maintain sufficient nursing staff to meet residents’ needs, resulting in frequent understaffing with as few as one or two CNAs for more than 40 residents, including many requiring incontinence care and two-person transfers. CNAs reported being unable to respond promptly to call lights, clear meal trays, or provide scheduled showers, and residents described long waits for assistance, prolonged periods in soiled briefs, and going more than a week without bathing. Review of shower records showed multiple residents without showers for 11–15 days, and one resident was observed with overgrown hair and beard, stating he had not showered in about two weeks and did not receive regular shaving help due to staff not having time. Staffing records documented numerous days with only one or two CNAs on duty despite a high census, and the facility assessment lacked clear, shift-specific staffing requirements for intermediate census levels, while leadership acknowledged ideal staffing levels but reported no specific contingency policy for call-ins.
The facility’s assessment of needed resources was incomplete, as it only identified staffing levels for census counts at or under 50 and for 63–68 residents in a 24-hour period, with no data for census levels between 51–62 or specific staffing needs by shift. The assessment also lacked a defined plan to maximize recruitment and retention of direct care staff and did not include a contingency staffing plan for non-emergency events that could affect resident care. The NHA acknowledged these gaps and confirmed there was no specific contingent staffing policy, relying instead on staff coming early, staying late, and lead nurses or management filling in on the floor.
Surveyors found that the facility failed to maintain adequate incontinence, catheter, and custodial supplies, leading staff to double-brief residents who preferred liners or chucks, cut up towels or use paper towels for perineal care due to a lack of washcloths, and improvise catheter setups when standard Foley bags were unavailable. A cognitively intact resident with urinary incontinence reported wearing two briefs because liners were out of stock, while another resident with CKD and an indwelling catheter reported missed monthly catheter changes and lack of preferred leg anchor bandages when catheter supplies ran out. Housekeeping staff reported running out of trash can liners, resulting in room trash with used briefs and wipes being emptied into a larger container without changing liners, leaving rooms odorous from soiled materials contacting unchanged trash bags.
A resident with a colostomy and parastomal hernia did not receive appropriate colostomy supplies when staff repeatedly used urostomy bags instead of correctly sized colostomy pouches, leading to fecal leakage and strong odors. A CNA reported that proper 38 mm colostomy bags had been unavailable for months, with only smaller 28 mm pouches in stock, and demonstrated having to rip urostomy bags to fit the stoma, which caused stool to clog the urine anti-reflux valve and back up. The DON, responsible for ordering supplies, initially stated the clear pouches were colostomy bags but later confirmed they were urostomy bags after observing care and an inventory showed only a partial box of 28 mm colostomy pouches. The resident, who values religious participation, reported embarrassment over the transparent, leaking pouch and associated odors and had previously voiced dissatisfaction with the current supplies.
A resident admitted with a sacral pressure ulcer did not have the hospital's wound care orders transcribed into the facility's records, resulting in the absence of documented treatment orders. Nursing staff provided wound care based on verbal reports rather than written orders, and changes in treatment were not formally documented until several days after admission.
The facility did not identify or address several critical areas—such as ABN, care plan updates, medication consents, abuse reporting, and PASARR—through its QAPI program. Issues within the MDS department contributed to these deficiencies, and the QAPI process failed to proactively recognize them before they were identified by surveyors.
Surveyors found that a medication room was repeatedly left unlocked due to a malfunctioning door, allowing unauthorized access when no staff were present. Inspections also revealed loose, unidentified pills in a medication cart and pharmacy totes containing discontinued and unreturned medications, including high-alert drugs, left unsecured in the medication room. Staff acknowledged the issues but were unsure why medications had accumulated or why the door remained unfixed, all in violation of facility policy requiring secure and orderly medication storage.
The facility did not provide required written notifications to residents regarding changes in Medicare and Medicaid coverage or the resulting changes in their financial responsibility. Several residents did not receive the appropriate SNF ABN form when their Medicare Part A services ended, and another resident was not informed in writing about changes to their Medicaid patient payment amount, leading to confusion and frustration.
The facility did not provide required written bed-hold policy information or transfer notifications to residents or their representatives when several residents were transferred to the hospital, nor did it notify the State LTC Ombudsman as required. Staff interviews and record reviews confirmed these omissions, which were attributed in part to busy conditions.
Due to insufficient staffing, multiple residents experienced missed showers, long wait times for assistance, and unmet personal hygiene needs. Residents and family members reported extended delays in call light responses and infrequent bathing, with some residents going weeks without a shower. Staff interviews and documentation confirmed that the facility did not consistently assign a replacement for the shower aide during absences, leading to significant gaps in care and resident frustration.
A resident with a diagnosis of bipolar disorder was admitted under a hospital exemption without a Level II PASARR, with the expectation of a short stay. When the resident became long-term, the facility failed to initiate the required PASARR II evaluation, and staff acknowledged the oversight, stating the process was not followed and the evaluation was not completed.
Two residents were admitted with significant medical needs—one with dysphagia and cognitive impairment, and another with a PICC line for IV antibiotics—yet baseline care plans addressing their high-risk conditions were not developed within 48 hours of admission, as confirmed by staff interviews and record review.
Two residents did not have comprehensive, person-centered care plans addressing their specific needs. One resident with a PICC line for IV antibiotics lacked a care plan focused on infection risks and line management, while another resident with a recent fracture and ongoing pain did not have care plan interventions for pain management or opioid monitoring. Nursing staff confirmed these omissions during interviews.
Two residents were administered psychotropic medications, including Haldol and PRN Xanax, without documented informed consent. Staff confirmed that no education or consent regarding the need, risks, benefits, or alternatives to these medications was present in the medical records, despite facility policy stating residents have the right to be informed about their treatment.
Staff served meals to residents on institutional trays in the dining rooms without removing plates and tableware, resulting in a meal service that residents reported was not similar to their home experience. Some residents, including those with moderate cognitive impairment and those cognitively intact, expressed dissatisfaction with this practice. The Certified Dietary Manager confirmed that staff do not consistently remove items from trays.
Two residents with severe cognitive impairment were involved in an incident where one resident groped another's breast in a common area, witnessed by staff. The victim attempted to defend herself and later expressed feelings of violation and distress. The perpetrator had a documented history of sexually abusive behaviors, and staff and family interviews confirmed the incident and its impact.
A resident with anxiety and intact cognition received a PRN antianxiety medication without documentation of specific anxiety-related behaviors or symptoms, and there was no evidence that non-pharmacological interventions were attempted prior to administration, contrary to facility policy.
Three residents were involved in an incident where a male resident with a history of sexually inappropriate behavior entered a room and inappropriately touched two female residents. Despite internal documentation and staff awareness of the incident, the facility did not report the abuse allegations to the State Agency as required by federal regulations.
Three residents were involved in an incident where a male resident with a history of sexually inappropriate behavior entered a room and touched two female residents under their blankets. Despite staff and administrator awareness of the event and prior documentation of similar behaviors, the facility did not conduct a required investigation into the abuse allegations, violating federal regulations and facility policy.
Surveyors found that required MDS assessments were not completed on time for four residents, including one whose death in facility assessment remained incomplete and three whose quarterly assessments were overdue. Nursing staff acknowledged missing the deadlines, and the NHA was unaware of the lapses.
Two residents with severe cognitive impairment were involved in a resident-to-resident abuse incident, where one resident groped another and the second responded physically. Despite documented behavioral symptoms and the witnessed event, care plans for both residents were not revised or updated with new interventions to address or prevent further incidents, as confirmed by the DON.
A resident with severe cognitive impairment and dementia exhibited frequent physical and sexual behavioral symptoms toward staff, including inappropriate touching and verbal aggression. Despite ongoing incidents documented in the medical record, staff interviews confirmed that no behavioral health assessment or intervention was provided, and the facility did not arrange for outside behavioral health services as required by policy.
The facility did not consistently document or follow up on pharmacy medication regimen review (MRR) recommendations for two residents, as required by policy. Although the EMR indicated that recommendations were made, the actual recommendations were missing from the records, and the DON was unable to provide them when requested.
A resident with a history of pain and psychiatric diagnoses received frequent PRN opioid medications without consistent documentation of pain assessments or attempts at non-pharmacological interventions prior to administration. The DON confirmed that facility practice required such documentation, but records showed this was not followed, and the facility's policy lacked guidance on opioid administration.
A resident with Crohn's disease and significant weight loss did not receive meals that accommodated their dietary preferences and medical needs, including a physician's order for double portions. The resident was served foods they could not tolerate and was not always provided with the required increased portions, due to incomplete dietary assessments and miscommunication among staff.
The facility failed to maintain adequate staffing levels, resulting in unmet care needs for residents. Two residents reported long call light response times and insufficient assistance, particularly for showers and bathroom needs. The Facility Assessment outlined specific staffing requirements, which were not met, and Resident Council meeting minutes consistently documented concerns about staffing. Interviews with the DON and NHA revealed a lack of awareness and explanation for these deficiencies.
The facility failed to provide prompt written responses to grievances for two residents, leading to frustration and feelings of being unheard. One resident submitted multiple complaints about food and other issues without receiving written responses, while another resident filed seven complaints about a loud neighbor, which were not properly documented or addressed. The facility's grievance policy requiring written responses within five days was not followed.
The facility failed to timely report a resident-to-resident altercation and the results of an investigation to the state agency. In one incident, a resident kicked another's wheelchair and used profanity, with the investigation summary submitted three months later. Another incident involved a resident yelling and swearing at another, which was not reported. The NHA acknowledged these reporting delays, contrary to the facility's Abuse Prevention Program policy.
The facility failed to investigate resident-to-resident altercations involving three residents. An incident between two residents was reported late, lacking interviews and follow-up observations. Another incident of a resident yelling and swearing was not investigated or reported. The facility's abuse prevention policy was not followed.
The facility did not post the required daily staffing information for direct care nursing personnel. Observations revealed that postings lacked the facility name and documentation of total and actual hours worked by nursing staff. A review of postings showed missing information, including total hours worked and census data. The DON was informed but did not provide an explanation.
A resident at high risk for falls was placed in a recliner with the footrest elevated, leading to a fall and a hip fracture. The LPN failed to perform a full assessment or follow physician orders for an x-ray, delaying treatment. The DON confirmed the LPN's negligence, resulting in their termination.
The facility failed to ensure the QAPI committee met quarterly with required members. The Medical Director or designee did not attend the 4/30/2024 meeting, and no attendance record was found for the 1/10/2024 meeting. Additionally, no meeting was held for the third quarter of 2023. The interim-NHA and DON were unable to locate the necessary QAPI documents, resulting in potential quality-of-care concerns for all 55 residents.
The facility failed to review resident rights with eight residents, leading to their lack of awareness and frustration. Staff N admitted to not reviewing these rights due to conflicts between residents during meetings, and the Nursing Home Administrator acknowledged the issue when informed.
The facility failed to provide adequate CNA staffing, resulting in delays in responding to call lights and potential adverse outcomes. Residents reported extended wait times for assistance, particularly during the night shift when only two CNAs were on duty. Staff interviews and call light logs confirmed these issues, highlighting the facility's inability to meet its own staffing guidelines.
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, resulting in the catheter drainage bag and tubing frequently being positioned incorrectly, either resting on the floor or placed above the bladder level. CNAs were observed mishandling the catheter bag, and the DON confirmed that such practices increase the risk of infection and cross-contamination.
A facility failed to assess a resident's capability for self-administration of medications. Despite the resident's cognitive intactness and multiple medical conditions, there was no order for self-administration. An LPN left the resident alone with medications without verifying intake or ensuring safety, and the DON confirmed no assessment was conducted, violating facility policy.
The facility failed to develop comprehensive care plans for two residents, leading to potential unmet needs. One resident experienced significant weight loss without a nutritional care plan, while another resident's activity preferences were not addressed despite moderate cognitive impairment and a long-term stay plan.
The facility failed to update care plans appropriately for two residents, resulting in care plans that did not reflect their needs. One resident experienced a fall with significant injuries, and the care plan was not updated to include new interventions. Another resident had a catheter-related pressure wound, and the care plan lacked necessary focus areas and interventions until the day of the surveyor's observation.
A resident with moderate cognitive impairment and multiple medical conditions experienced a worsening catheter-associated pressure injury due to the facility's failure to change and rotate the catheter securing device as ordered. The nurse did not document the wound's characteristics or measurements, and there were inconsistencies in the Medication Administration Record (MAR) and Treatment Administration Records (TAR). The Director of Nursing (DON) confirmed the wound began as a small tear from catheter dislodgement, but there was no proper documentation or assessments to track the wound's healing.
The facility failed to ensure timely physician response to MRR pharmacy recommendations and did not follow physician orders for a resident with multiple diagnoses, including GERD and dementia. The pharmacist recommended a decrease in pantoprazole dosage, which the physician agreed to after a delay, but the order was never implemented. The DON confirmed the MRR signed by the physician was never written as an order, and no facility policy on MRRs was provided during the survey.
The facility failed to follow up on routine dental services for a resident, resulting in the resident's diet being downgraded to a pureed diet. The resident's dentures were sent out for repair, but no follow-up appointment was made, leading to the resident continuing on a pureed diet due to poor communication between the dental office and facility staff.
The facility failed to ensure dignified care experiences for three residents. One resident was left on the toilet for 45 minutes during a shift change, another was exposed to her roommate during toileting, and a third was left uncovered and exposed to the view of other residents. The DON confirmed the importance of maintaining resident privacy and dignity during care.
Failure to Maintain Sufficient Nursing Staff Leading to Missed Care and Hygiene
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ care needs and ensure their safety, as evidenced by multiple staff and resident interviews, record reviews, and observations. A complaint to the State Agency reported that only two nurses were in the building when there should have been at least three, and that the DON, Infection Control Nurse, and Administrator were absent, leaving staff feeling they were “drowning” with no help. A CNA reported the facility was constantly understaffed, often with just two CNAs for a census of 50 or more residents, many of whom were incontinent, resulting in residents sitting in excrement longer than appropriate. Another CNA described “strangely low” staffing, with night-shift CNAs finding residents already asleep with dirty dinner trays still in front of them because day-shift CNAs lacked time to clear them, and noted that there were usually only two CNAs at night and sometimes only one, with travel CNAs occasionally walking out upon realizing they were the only CNA on duty. Review of daily staffing sheets from November through March showed 46 occasions with only two CNAs on duty and seven occasions with only one CNA, while the census ranged from 42–58 residents, 26% of whom required two-person transfers. Residents reported delays and missed care directly related to low staffing. One resident stated there were often only one or two CNAs working the entire building, leading to extended call light response times, prolonged periods in soiled briefs, and going over a week without bathing. Another resident, incontinent of urine, reported several nights with only one CNA on duty and estimated waiting an hour or more for assistance after activating her call light. A CNA confirmed that showers were frequently missed due to low staffing and explained that on a day when three CNAs were scheduled, one called in sick, leaving only two CNAs and making it “nearly impossible” to help residents shower. Review of the shower binder showed that several residents had not received showers for 11–15 days, and one resident had only one shower recorded for the entire month. One resident was observed with a long beard and overgrown hair and reported not having had a shower in about two weeks and not receiving regular shaving assistance, which staff attributed to lack of time. The facility assessment lacked specific staffing needs by shift and for census levels between 51–62, and the NHA acknowledged that ideal staffing would be three nurses and three CNAs at a minimum but stated that what the facility wanted and what it could obtain were different, and that there was no specific contingency policy for staff call-ins.
Incomplete Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to maintain a comprehensive facility-wide assessment that identified the resources necessary to care for residents competently during routine operations and emergencies. Review of the facility assessment dated 1/19/26 showed an incomplete staffing plan that only specified the number of staff needed for a census at or under 50 residents in a 24-hour period and for a census of 63–68 residents in a 24-hour period, with no data for census levels between 51–62 residents and no breakdown of specific staffing needs by shift. Further review showed the assessment did not include a plan to maximize recruitment and retention of direct care staff and did not establish a contingency staffing plan for events that do not trigger the facility’s emergency plan but could affect resident care. In an interview, the NHA acknowledged the lack of specific staffing needs by shift and census and confirmed there was no specific contingent staff policy, stating instead that personnel may come early or stay late and that lead nurses or management may help fill in on the floor.
Inadequate Supply of Incontinence, Catheter, and Custodial Products
Penalty
Summary
The deficiency involves the facility’s failure to maintain adequate supplies of incontinence products, urinary catheter components, and custodial items necessary for trash removal, resulting in care that did not align with physician orders or residents’ preferences and goals. A complaint to the State Agency reported limited supplies of briefs, wipes, chucks, panty liners, and trash bags. Multiple CNAs reported that the facility was frequently out of correctly sized briefs, liners, chucks, and washcloths, and that staff were directed to use reusable washcloths instead of disposable wipes due to plumbing issues, which led to an extreme shortage of washcloths. Night staff reported having to cut up towels or use paper towels for perineal care when washcloths were unavailable. A resident with urinary incontinence and an amputation below the right knee, cognitively intact and frequently incontinent per the MDS, reported wearing two briefs because the facility had run out of liners, which she preferred to use with a brief to avoid soaking the bed, and described this as not ideal. CNAs confirmed that several residents who were heavy wetters and preferred liners or chucks in addition to briefs were instead placed in two briefs due to the lack of liners and chucks. A facility-wide tour with housekeeping staff showed only 13 washcloths on one hall, none on two other halls, and no clean washcloths ready in laundry, despite the DON later indicating there was an unopened box of washcloths stored on a high shelf in the laundry room that had not been accessed. The facility also failed to maintain adequate urinary catheter supplies and custodial trash supplies. A CNA reported frequent shortages of colostomy supplies and correct urinary catheter components, and documentation showed that when a resident self-removed a Foley catheter, the facility was out of Foley bags, leading staff to use an 18F Foley with a leg bag instead. Another cognitively intact resident with chronic kidney disease, obstructive and reflux uropathy, benign prostatic hyperplasia, and an indwelling urinary catheter stated that there had been times catheter supplies ran out and his scheduled monthly catheter change could not be done, and that requested leg anchor bandages were unavailable. Housekeeping staff reported that the facility had completely run out of trash can liners during the prior week, requiring room trash to be emptied into a large trash without changing liners, leaving rooms with used briefs or wipes odorous due to soiled materials leaking onto unchanged trash liners.
Failure to Provide Appropriate Colostomy Supplies and Care
Penalty
Summary
The facility failed to provide appropriate colostomy supplies for a resident with a history of colon cancer, colostomy, and parastomal hernia, resulting in ongoing problems with ostomy management. The resident had a BIMS score indicating moderate cognitive impairment and a care plan goal that ostomy care would be managed appropriately and stool would not leak. A CNA reported that staff had been using urostomy bags on the resident’s colostomy site for months because the correct 38 mm colostomy pouches were not in stock, and only 28 mm colostomy pouches were available. During an observation of colostomy care, the resident’s transparent ostomy bag was nearly full of feces, with fecal matter leaking from the upper right portion of the stoma and a strong, noxious odor in the room. The CNA obtained a urostomy bag from the resident’s nightstand and demonstrated that the plastic had to be ripped to fit the resident’s stoma and that the bag contained an anti-reflux valve designed for urine, which the CNA stated became clogged with stool and led to backups and fecal leakage. The DON, who was responsible for ordering medical supplies, initially stated the clear pouches in use were colostomy bags and that the facility was working on obtaining opaque bags per the resident’s preference. However, when asked to oversee the colostomy care, the DON confirmed that the pouch in use was a urostomy bag and acknowledged that using a urostomy bag instead of a colostomy bag could restrict fecal flow and lead to backup, leakage, or infection. An inventory of the supply closet revealed only a partial box of 28 mm colostomy pouches, with no appropriate-sized colostomy bags available for the resident. The resident reported significant embarrassment related to the transparency of the pouch and the associated odors from leakage, stating that he had not previously experienced such issues with his colostomy and that he had requested a different type of pouch. He also reported that participation in religious services was very important to him but that he sat in the back and avoided socializing due to concerns about the appearance and smell of his colostomy bag.
Failure to Transcribe and Implement Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to accurately transcribe and implement physician orders for pressure ulcer treatment for a resident admitted with an active diagnosis of a sacral pressure ulcer, altered mental status, and osteoarthritis. The hospital discharge summary specified that Medihoney should be applied and covered with Mepilex daily to the sacral pressure ulcer. However, upon admission, the facility did not enter this pressure ulcer care order into the resident's order set. Documentation from the Director of Nursing (DON) indicated that the pressure ulcer was treated with Medihoney and Mepilex on admission, but no formal treatment order was found in the resident's records. Further review showed that on a later date, a Registered Nurse (RN) noted changes in the wound's condition and reported a change in treatment to Hydrogel and Mepilex after consulting with a Nurse Practitioner. Despite this, there was no documentation of a change order or any pressure ulcer treatment orders until several days after admission. Interviews with the DON and RN revealed that care was provided based on verbal reports rather than documented orders, and neither could locate the necessary treatment orders or explain the lack of documentation.
Failure to Identify and Address Key Deficiencies Through QAPI
Penalty
Summary
The facility failed to identify and address multiple areas of improvement through its Quality Assurance and Performance Improvement (QAPI) program. Surveyors identified five specific concerns that were not proactively recognized by the facility's QAPI process: Advanced Beneficiary Notification (ABN), care plan updates, medication consents, proper reporting of abuse, and Preadmission Screening and Annual Resident Review (PASARR). During an interview, the Nursing Home Administrator (NHA) acknowledged that while there were Performance Improvement Plans (PIPs) in progress for wound care and weight measurement, PIPs for ABN and medication consents were only initiated after these issues were brought up by the survey team. The NHA also reported ongoing issues within the MDS department, which impacted timely ABN issuance, effective care planning, PASARR coordination, and completion of medication consents. The NHA described that the Interdisciplinary Team (IDT) met daily to identify concerns and that staff could report issues to unit managers, IDT members, or the compliance officer, but there was no anonymous reporting mechanism. The NHA was unable to explain why the QAPI program had not previously identified the concerns found during the recertification survey. The lack of proactive, system-level interventions and failure to identify these deficiencies through the QAPI process placed residents at risk for harm.
Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors identified multiple failures in the facility's medication storage and security practices. The main medication room near the front entrance and administration offices was repeatedly found to have a malfunctioning door handle and lock, resulting in the room being left unlocked and unsecured on several occasions. Staff, including RNs and the DON, acknowledged the issue and stated that maintenance had attempted repairs, but the door continued to fail to latch and lock properly. During these times, the medication room was accessible to unauthorized personnel, and there were periods when no staff were present to monitor access. In addition to the unsecured medication room, an inspection of a medication cart revealed loose, unidentified pills in multiple drawers and a plastic bag containing a tube of prescription medication dated over a year prior. The LPN accompanying the surveyor stated that nurses are responsible for cleaning the carts and ensuring medications are not left loose or mixed, but acknowledged that such issues should not occur. Furthermore, the main medication room contained multiple pharmacy totes on the floor, filled with medications from discharged or deceased residents and discontinued prescriptions. These included high-alert medications such as vancomycin IV bags, immunization vials, antidepressants, injectable blood thinners, insulin pens, and lidocaine patches. The LPN was unsure why these totes had accumulated and reported that pharmacy typically picks them up nightly, but they had been present for several days. Facility policy requires all drugs and biologicals to be stored securely in their original containers, with proper labeling, and in locked compartments accessible only to authorized personnel. The policy also mandates that discontinued or outdated medications be returned to the pharmacy or destroyed, and that medication storage areas be kept clean, safe, and orderly. The observed practices, including unsecured storage areas, accumulation of unreturned medications, and improper handling of medication carts, were inconsistent with these requirements and contributed to the cited deficiency.
Failure to Notify Residents of Changes in Medicare/Medicaid Coverage and Financial Liability
Penalty
Summary
The facility failed to provide required notifications to residents regarding changes in Medicare and Medicaid coverage and the resulting financial liability for services not covered. Specifically, three residents whose Medicare Part A services had ended did not receive the appropriate Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, CMS-10055) as required. Documentation indicated that the correct form was not used due to a recent change in business office staff, and the new staff member had not been properly educated on the correct process. The Nursing Home Administrator confirmed that the facility had not provided the up-to-date SNF ABN notice to residents discharging from Medicare Part A services over the past year. Additionally, a review of another resident's records revealed that changes in Medicaid coverage, which affected the resident's monthly patient payment amount, were not communicated in writing to the resident. The business office coordinator acknowledged that the facility did not provide written notice of these changes, assuming that Medicaid would notify the resident directly. The resident, who was cognitively intact, expressed frustration at not being informed of the increased charges prior to receiving his monthly statement. The facility's failure to notify residents of changes in coverage and financial responsibility was confirmed through interviews and record reviews.
Failure to Provide Required Bed-Hold and Transfer Notifications
Penalty
Summary
The facility failed to provide required written documentation and notifications related to bed-hold policies and transfer notices for multiple residents who were transferred to the hospital. In several instances, residents were sent out to the emergency department due to acute changes in condition, such as confusion, altered mental status, and suspected appendicitis. Despite these transfers, there was no evidence in the medical records that the residents or their representatives received written information about the facility's bed-hold policy or written notification of the transfer. Additionally, there was no documentation that the Office of the State Long-Term Care Ombudsman was notified of the transfers as required. Specifically, staff interviews and record reviews confirmed that written bed-hold policies and transfer notifications were not provided at the time of transfer for the residents involved. Facility policy requires that residents and their representatives be informed in writing of bed-hold and return policies prior to transfer, and that the ombudsman be notified of such events. However, documentation and staff statements revealed these steps were not completed, with staff citing workload and busy conditions as reasons for the omissions.
Failure to Provide Adequate Staffing Resulting in Missed Care and Hygiene Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, resulting in missed showers, extended wait times for assistance, and unmet personal hygiene needs. Multiple residents, including those with significant medical conditions such as enterococcus bacteremia, neuropathy, traumatic brain injury, and incontinence, reported long delays in response to call lights and infrequent bathing. One resident stated that it took over 45 minutes for staff to respond to his call light, while another was unable to brush his teeth or access personal hygiene items due to lack of staff assistance. Family members and residents consistently reported frustration with the lack of timely care. Observations and interviews revealed that the facility's shower aide was frequently reassigned to floor duties due to staff shortages, resulting in residents missing scheduled showers. Documentation showed that some residents went weeks without a shower, with no records of refusals or alternative care being provided. For example, one resident received only a handful of showers over a three-month period, with gaps of up to 38 days between showers. The facility did not assign a replacement shower aide during the regular aide's absence, and therapy staff only provided showers to a limited number of residents during this time. Staff interviews confirmed that low staffing levels led to missed showers and delays in care. The Director of Nursing acknowledged that no replacement was scheduled for the shower aide during absences, and that therapy staff only assisted with showers for residents already receiving therapy. Group interviews with residents further corroborated that many did not receive showers for extended periods, particularly when the shower aide was on vacation. These failures resulted in residents experiencing feelings of frustration, helplessness, and anger, as well as observable declines in personal hygiene.
Failure to Complete Required PASARR II Evaluation for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a Level II PASARR (Preadmission Screening and Resident Review) evaluation was completed for a resident with a known diagnosis of bipolar disorder, a serious mental illness. The resident was admitted to the facility following a hospital stay under a PASARR hospital exemption, which allowed for admission without a Level II PASARR on the condition that the resident would require less than 30 days of nursing facility services. The exemption documentation specified that if the plan changed and the resident required a longer stay, the OBRA Office should be notified for appropriate follow-up. Despite the resident becoming a long-term resident after multiple admissions, the facility did not initiate a Level II PASARR evaluation as required. The MDS nurse acknowledged that the resident should have had a PASARR II completed due to the extended stay but stated that the process had not been followed and the resident "fell through the cracks." The facility did not have a PASARR II on file for the resident at the time of the survey.
Failure to Establish Baseline Care Plans for High-Risk Admissions
Penalty
Summary
The facility failed to provide appropriate baseline care planning for two residents upon admission, specifically neglecting to address high-risk focus areas. One resident was admitted with Parkinson's disease and dysphagia, and was found to have a BIMS score indicating cognitive impairment. Despite these conditions, there was no baseline care plan in place to address the resident's difficulty swallowing and associated high risk of choking. Another resident was admitted with a diagnosis of Enterococcus bacteremia and was receiving intravenous antibiotics via a PICC line. This resident was cognitively intact, but the care plan did not include a baseline focus on the management and risks associated with the PICC line, such as potential complications and infections. Interviews with facility staff confirmed that baseline care plans should have been established for both residents to address their specific high-risk needs. The facility's policy requires that care plans incorporate goals and objectives based on comprehensive assessments and that these plans be accessible to all disciplines. However, the absence of baseline care plans for these residents' critical conditions represented a failure to meet immediate care needs as required by facility policy and regulatory standards.
Failure to Develop Comprehensive Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents. One resident was admitted with a diagnosis of Enterococcus bacteremia and was receiving intravenous antibiotics via a PICC line. Despite being cognitively intact and at risk for complications and infections related to the PICC line, there was no comprehensive care plan completed for this resident. Interviews with nursing staff confirmed that a care plan should have been in place, particularly addressing the PICC line and associated risks. Another resident, admitted with a left ankle fracture and diagnoses including anxiety and schizophrenia, was experiencing almost constant pain and was receiving both scheduled and PRN opioid pain medications. The care plan for this resident did not include specific focus areas, goals, or non-pharmacological interventions related to pain management or opioid use, nor did it address monitoring for adverse effects of these medications. Staff interviews confirmed the absence of these critical care plan components, despite the resident's ongoing pain and frequent administration of opioid medications.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to two residents. One resident with moderate cognitive impairment and diagnoses including traumatic brain injury and bipolar disorder was receiving Haldol, an antipsychotic medication, without any documented informed consent in the electronic medical record. Staff interviews confirmed that no signed consent or documentation of education regarding the need, risks, benefits, or alternatives to the medication was present for this resident. The process for obtaining informed consent was described as a responsibility of providers and nursing staff, but audits by social services did not reveal any evidence of consent for the medication in question. Another resident, who was cognitively intact and had a diagnosis of anxiety, was prescribed Xanax on an as-needed basis, also without any documented informed consent in the medical record. The DON confirmed that no consents were obtained for either the Haldol or the PRN Xanax. Review of facility policies showed that while one policy addressed physician responsibilities regarding antipsychotic medication use, it did not include requirements for informing residents or their representatives about the need for the medication or its risks and benefits. Another policy stated residents have the right to be informed about their condition and treatment options, but this was not followed in these cases.
Failure to Provide Homelike Meal Service Environment
Penalty
Summary
The facility failed to provide a homelike environment for residents by serving meals on institutional trays in the dining rooms, rather than removing the items from the trays before serving. Observations on multiple occasions showed that staff consistently served breakfast and lunch to residents with plates, cups, and tableware left on service trays, both in the main and rehabilitation unit dining areas. Interviews with residents revealed that several did not feel the meal service resembled their experience at home, with one resident indicating moderate cognitive impairment and others being cognitively intact. The Certified Dietary Manager acknowledged that staff do not always remove items from trays as preferred.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to monitor and prevent resident-to-resident sexual abuse involving two residents, both of whom had severe cognitive impairment as indicated by their BIMS scores of 3 out of 15 and diagnoses of dementia and Alzheimer's Disease. On the date of the incident, one resident was observed groping another resident's breast while both were seated in a common area. Staff witnessed the incident, with the victim attempting to defend herself by repeatedly slapping the perpetrator's shoulder. The victim later reported feeling violated and upset, and her family member confirmed her distress following the event. Documentation and interviews revealed that the perpetrating resident had a documented history of physical and sexually abusive behaviors toward others, occurring every 4 to 6 days. Staff statements and facility records confirmed the sequence of events, including the immediate reactions of both residents and the staff's awareness of the incident. The facility's policy on abuse prevention was reviewed, which states residents' rights to be free from all forms of abuse, including sexual abuse. The Nursing Home Administrator acknowledged that sexual abuse had occurred during the incident.
Failure to Document Rationale and Non-Pharmacological Interventions for PRN Antianxiety Medication
Penalty
Summary
The facility failed to document specific behaviors, signs, and symptoms of anxiety that justified the administration of a PRN antianxiety medication for one resident. The resident, who was cognitively intact and had a diagnosis of anxiety, had an active physician order for PRN Xanax. On one occasion, the medication was administered with the reason documented as 'generalized, not feeling well,' but there was no documentation of the specific anxiety-related behaviors or symptoms that prompted the use of the medication. Additionally, the electronic medical record did not contain evidence that non-pharmacological interventions were attempted prior to administering the PRN medication, as required by facility policy. The Director of Nursing confirmed the absence of documentation regarding both the specific need for the medication and the use of non-pharmacological interventions. The facility's policy mandates that such interventions and their effects be documented as part of the care planning process.
Failure to Report Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to identify and report allegations of abuse involving three residents, as required by federal regulations. One resident, who was cognitively intact and recovering from a left ankle fracture, reported that a male resident entered her room uninvited, placed his hand under her blanket, and attempted to move his hand up her thigh. She resisted and called for help, after which the male resident moved to her roommate's bed and repeated similar behavior. The roommate, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was unable to answer questions about the incident. Both incidents were witnessed or reported to staff, and the nurse practitioner and guardians were notified, but the events were not reported to the State Agency as required. The male resident involved had a documented history of sexually inappropriate behavior toward both staff and other residents, including multiple incidents of inappropriate touching and comments in the weeks leading up to the event. Progress notes indicated ongoing behavioral issues, and the care plan included interventions to monitor and redirect the resident away from female residents. Despite these documented behaviors and the specific incident involving two female residents, the facility did not submit a report of the abuse allegation to the State Agency. Interviews with staff confirmed that the incident was reported internally to the Nursing Home Administrator, who stated that she did not report the event to the State Agency because she believed there was no physical contact. However, both the resident and a registered nurse confirmed that inappropriate touching had occurred. The facility's own abuse prevention policy required investigation and reporting of all abuse allegations within required timeframes, but this was not followed in these cases.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving three residents. One cognitively intact resident with a left ankle fracture reported that a male resident in a wheelchair entered her room uninvited, placed his hand under her blanket, and attempted to move his hand up her thigh. After she stopped him, the male resident moved to her roommate, who was severely cognitively impaired and dependent for all activities of daily living, and similarly reached under her blanket. The incident was witnessed by staff who responded to calls for help. The male resident involved had a documented history of severe cognitive impairment and repeated sexually inappropriate behaviors toward both staff and other residents, including multiple incidents of inappropriate touching and sexual comments. Despite this history and the specific incident involving two female residents, the facility did not conduct an investigation into the event as required by their abuse prevention policy. The administrator and staff confirmed awareness of the incident but acknowledged that no formal investigation was initiated. Documentation in the medical records and staff interviews confirmed that the incident was reported to facility leadership, and that the male resident's behaviors had been previously identified and care planned for monitoring and redirection. However, the lack of a thorough investigation into the specific allegations of abuse on the date in question constituted a failure to respond appropriately to alleged violations, as required by federal regulations and the facility's own policies.
Failure to Complete Timely MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed in a timely manner for four residents out of sixteen reviewed. Specifically, one resident's MDS assessment related to death in the facility was noted as 'in process' and had not been completed or submitted as required. For three other residents, quarterly MDS assessments were not completed within the required 120-day timeframe, with the assessments only being completed after the deadline had passed. During interviews, a registered nurse acknowledged that several resident assessments were late and had been missed, and that the team was unaware of the incomplete death in facility record for one resident. The nursing home administrator was also not aware that the required MDS assessments had not been completed on time for the affected residents. These findings were based on both record review and staff interviews.
Failure to Revise Care Plans After Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to revise care plans to address supervision and behavioral interventions following a resident-to-resident abuse incident involving two residents with severe cognitive impairment. One resident, diagnosed with Alzheimer's Disease, anxiety, and depression, and another resident with dementia, both scored 3 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The second resident exhibited physical behavioral symptoms toward others, including hitting, kicking, pushing, scratching, grabbing, and sexually abusing others every 4 to 6 days, as documented in the medical record. On a specific date, the second resident groped the first resident's breast, which was witnessed by staff. The first resident responded by repeatedly slapping the second resident's shoulder, stating that the action was to make the other resident stop. Despite this incident, a review of the care plans for both residents revealed that no new interventions or revisions were made to address the incident or to prevent recurrence. The Director of Nursing confirmed that no changes had been made to the care plans following the event.
Failure to Provide Behavioral Health Services for Resident with Severe Behavioral Symptoms
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with severe cognitive impairment and a diagnosis of dementia, who exhibited frequent and escalating physical and sexual behavioral symptoms directed toward staff and others. Documentation in the resident's medical record and progress notes detailed multiple incidents over several months, including inappropriate touching, grabbing, verbal aggression, and sexual advances toward staff during care and transfers. Despite these ongoing behaviors, there was no evidence that the resident received any behavioral health assessment or intervention from outside behavioral health services. Interviews with facility staff, including the Social Services Designee, NHA, LPN, and DON, confirmed that the resident had not been seen by behavioral health professionals, and staff were either unaware of or had not initiated referrals for behavioral support. The facility's own policy required the provision of behavioral health services as needed, but no such services were provided for this resident, as confirmed by staff statements and the absence of documentation in the medical record.
Failure to Document and Follow Up on Pharmacy Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure consistent follow-up and documentation of monthly medication regimen reviews (MRRs) for two residents. For both residents, the electronic medical record (EMR) indicated that pharmacy recommendations were made on specific dates, but there was no documentation or pharmacy report available in the EMR detailing what those recommendations were. This lack of documentation meant that the recommendations from the pharmacist were not accessible for review or follow-up by the care team. When questioned, the DON stated that recommendations from the pharmacy are typically received via email and that nursing staff are responsible for auditing charts to ensure follow-up on pharmacy recommendations. However, the DON was unable to provide the missing pharmacy recommendations for the two residents in question. The facility's policy requires that consultant pharmacist findings and recommendations be documented and filed in the resident's chart in an easily retrievable format, but this was not done for the affected residents.
Failure to Document Pain Assessments and Non-Pharmacological Interventions Prior to PRN Opioid Administration
Penalty
Summary
The facility failed to consistently document pain assessments and the use of non-pharmacological interventions prior to administering PRN opioid pain medications for a resident with a history of left ankle fracture, anxiety, and schizophrenia. The resident was cognitively intact and experienced almost constant pain, receiving both scheduled and PRN pain medications, including oxycodone and tramadol. Review of the medication administration records over a two-month period showed that oxycodone was administered 69 times and tramadol 35 times, but only four pain assessments were documented for each medication. There was no documentation of any non-pharmacological interventions attempted before administering the PRN opioids. The Director of Nursing confirmed that the facility's standard practice required nursing staff to attempt non-pharmacological interventions and document both the intervention and the result prior to administering PRN pain medication, as well as to complete a pain assessment before opioid administration. However, the facility's medication management policy did not include any process or information related to the administration of opioid medications, contributing to the lack of consistent documentation and assessment.
Failure to Accommodate Dietary Preferences and Orders for Resident with Crohn's Disease
Penalty
Summary
The facility failed to accommodate a resident's dietary preferences and medical needs, specifically for a resident with Crohn's disease, abnormal weight loss, and protein-calorie malnutrition. Despite a physician's order for double food portions and the resident's stated intolerances to certain foods such as processed meats, cheeses, fried foods, excess sugar, wheat flour, and regular milk, the resident was repeatedly served meals containing these items. The resident reported not being asked about his food preferences or intolerances and expressed ongoing hunger, noting that he did not always receive the ordered double portions. Observations confirmed that the resident received standard portion sizes and was not offered substitutes when served foods he could not eat. Interviews with facility staff revealed that the Certified Dietary Manager had not completed the required Nutritional Preferences Assessment for the resident, resulting in the resident's preferences not being reflected on meal tray cards. The Nursing Home Administrator acknowledged that staff misinterpreted the dietary order, leading to inconsistent provision of double portions. Facility policy required that diets be determined in accordance with resident preferences and that a tray identification system be used to ensure correct meal delivery, but these procedures were not followed in this case.
Staffing Deficiencies Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of its residents, as evidenced by interviews and record reviews. A resident reported a shortage of nurses and CNAs, leading to extended call light response times and unmet care needs, such as not receiving a requested shower. The resident's medical record confirmed the lack of a shower on a specific date, and the care plans did not document shower frequency preferences. Another resident expressed similar concerns about staffing shortages, particularly regarding delays in assistance for bathroom needs, which caused discomfort. The Facility Assessment documented specific staffing requirements, which were not met during the reviewed periods in July and November. Staffing sheets revealed that no shifts had adequate numbers of nurses or CNAs according to the Facility Assessment. Resident Council meeting minutes consistently documented concerns about call light response times, but these concerns were not addressed in the Department Response forms. Interviews with the DON and NHA highlighted a lack of awareness and explanation for the staffing deficiencies, despite the DON's involvement in the Facility Assessment updates.
Failure to Provide Written Responses to Resident Grievances
Penalty
Summary
The facility failed to provide prompt written responses to grievances for two residents, resulting in feelings of frustration and being unheard. Resident #36, who was cognitively intact with a BIMS score of 15, had submitted multiple complaints to the facility and the State Agency, requesting written responses that were never provided. The Social Services Director acknowledged receiving grievances but did not log them properly or provide written responses to the resident. The Certified Dietary Manager recalled a food-related complaint from Resident #36 but did not have a formal concern form, and the grievance was not logged appropriately. Resident #37, also cognitively intact with a BIMS score of 15, submitted seven complaints over a week regarding a loud resident. The Social Services Director admitted to not completing the grievance forms in a timely manner and was found filling in responses during the survey. The grievances lacked proper documentation, including dates of review by the Nursing Home Administrator and signatures. Resident #37 confirmed not receiving any written responses to her complaints. The facility's grievance policy stated that a written summary of the investigation results should be provided within five working days, but this was not adhered to. The lack of proper documentation and failure to provide written responses to grievances led to the citation, as residents felt their concerns were not being addressed adequately.
Failure to Timely Report Resident Altercations
Penalty
Summary
The facility failed to timely notify the state agency of a resident-to-resident altercation and did not report the results of an investigation in a timely manner for three residents involved in incidents of abuse. In one case, a facility-reported incident (FRI) was submitted to the state agency two days after a witnessed altercation between two residents, where one resident kicked the back of another's wheelchair and used profanity. The investigation summary for this incident was submitted three months later, which was a significant delay. The Nursing Home Administrator (NHA) acknowledged that the FRI should have been submitted within 24 hours and the investigation results within five days. Another incident involved a resident who began yelling and swearing at another resident in the activity room. The nurse on duty documented the incident but did not report it to the state agency. The NHA agreed that this incident should have been reported within two hours, with an investigation initiated and followed up with a five-day report to the state agency. The facility's Abuse Prevention Program policy, revised in December 2016, requires timely investigation and reporting of abuse allegations as per federal requirements, which was not adhered to in these cases.
Failure to Investigate Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate resident-to-resident altercations involving three residents. An incident between two residents was reported to the state agency, but the investigation summary was submitted three months later. The facility's administrator could not provide a complete investigation file, lacking interviews, witness statements, and follow-up observations. The incident report was not completed, and the administrator acknowledged the absence of necessary documentation, attributing it to the tenure of the previous administrator. Another incident involved a resident yelling and swearing at another resident, which was not investigated or reported to the state agency. The facility's policy on abuse prevention requires investigation and reporting of such incidents, but this was not adhered to. The administrator agreed that the situation should have been investigated and reported, indicating a failure to follow the facility's abuse prevention program.
Failure to Post Required Daily Staffing Information
Penalty
Summary
The facility failed to post the required daily staffing information for direct care nursing personnel. On 11/12/24, the daily nurse staff posting was observed to be incomplete, lacking the facility name and documentation of the total number and actual hours worked by licensed and unlicensed nursing staff for each shift. A review of staff postings from 11/1/24 through 11/13/24 revealed that none contained the facility name, and the forms did not include columns for actual hours worked. Additionally, the total hours worked for each category of nursing staff were left blank on multiple dates. A posting dated 11/04 did not document the census for the night shift. The Director of Nursing was informed of these deficiencies but did not provide an explanation for the missing information.
Failure to Prevent Fall and Provide Adequate Post-Fall Care
Penalty
Summary
The facility failed to implement appropriate interventions to prevent a fall for a resident identified as R601, who was at high risk for falls due to cognitive impairment and unsteadiness on feet. R601 had a history of falls, including one with a major injury. On the day of the incident, R601 was placed in a recliner chair with the footrest elevated, which was considered a restraint, and left unattended. This positioning led to R601 attempting to self-ambulate, resulting in a fall and a right hip fracture. The incident was compounded by inadequate post-fall care. After the fall, R601 was found on the floor by a CNA, who called for an LPN. The LPN did not perform a full head-to-toe assessment and instructed CNAs to move R601 back to bed without using a mechanical lift, contrary to proper post-fall procedures. The LPN also failed to follow through with the physician's order for an immediate x-ray, delaying the diagnosis and treatment of the hip fracture. Interviews with staff revealed discrepancies in the handling of the situation. The Director of Nursing confirmed that the LPN had placed R601 in the recliner and failed to complete necessary assessments and follow physician orders. The LPN's actions were deemed gross negligence, leading to their termination. The lack of proper supervision and failure to adhere to post-fall protocols directly contributed to the harm experienced by R601.
Failure to Meet QAPI Committee Requirements
Penalty
Summary
The facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members. Specifically, the Medical Director or designee did not attend the meeting held on 4/30/2024, and no attendance record was found for the meeting held on 1/10/2024. Additionally, no meeting was held for the third quarter of 2023, as confirmed by the Director of Nursing (DON) and the interim-Nursing Home Administrator (NHA H). The DON reported that information from the third quarter of 2023 was included in the October-December 2024 meeting on 1/10/2024, but no separate meeting was held for the third quarter of 2023. The interim-NHA H was new and unsure where the previous NHA kept the QAPI documents. Despite calling the previous NHA in the presence of the surveyor, the DON was unable to locate the necessary QAPI information for review. The missing attendance records and confirmation of meetings were not provided by the survey exit on 5/15/2024. The facility's QAPI plan, last reviewed on 8/22/2023, mandates that the QA Committee meet at least quarterly and include specific members such as the Director of Nursing Services, the Medical Director or designee, the administrator, the Infection Control and Prevention officer, and a pharmacy representative. The failure to adhere to these requirements resulted in the potential for quality-of-care concerns for all 55 residents in the facility.
Failure to Review Resident Rights
Penalty
Summary
The facility failed to review resident rights with eight residents, leading to their lack of awareness of these rights. During a group meeting, the residents expressed frustration and confusion about their rights, asking the surveyor to explain them. The resident council president confirmed that resident rights were not reviewed at the monthly meetings. Review of the resident council meeting minutes from the past three months showed no mention of resident rights, despite concerns related to dignified call light answering and missing items being raised. Staff N, who was present at these meetings, admitted to not reviewing resident rights due to conflicts between residents that prolonged the meetings. Staff N did not involve Social Services or nursing management to address these conflicts, which further disrupted the meetings and prevented the review of resident rights. The Nursing Home Administrator (NHA) acknowledged the issue when informed and planned to mail a copy of the residents' rights to their representatives and review them in the next resident council meeting. The facility's policy on resident rights states that residents must be informed of their rights in writing and in a language they understand, both at admission and during their stay. However, this policy was not followed, resulting in residents being unaware of their rights and experiencing undignified communication from staff when requesting assistance or timely care and medications.
Inadequate CNA Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate staffing of Certified Nursing Assistants (CNAs) to meet the needs of residents, resulting in delays in responding to call lights and potential adverse outcomes. Observations, interviews, and record reviews revealed that residents experienced frustration and extended wait times for assistance, particularly during the night shift when only two CNAs were on duty for the entire facility. This staffing deficiency was evident in the experiences of three specific residents and several others who reported similar issues during a group meeting with surveyors. One resident, who was cognitively intact, reported waiting too long for their call light to be answered, leading to incontinence. Another resident with moderate cognitive impairment also expressed concerns about insufficient staffing and the rushed demeanor of the aides. The facility's call light logs corroborated these complaints, showing multiple instances where residents waited over 20 minutes, and sometimes over an hour, for assistance. The facility's staffing records confirmed that there were often only two CNAs on duty during the night shift, which was significantly below the facility's own assessment of required staffing levels. Interviews with staff members, including CNAs and the Director of Nursing (DON), further highlighted the impact of low staffing levels. Staff reported feeling overwhelmed and unable to provide timely care, leading to residents being left wet or in the same position for extended periods. The DON acknowledged the staffing deficits and confirmed that the facility's current staffing levels did not meet the needs of the residents, particularly during the night shift. The facility's policy and assessment indicated that more CNAs were needed to ensure adequate care, but these guidelines were not being followed, resulting in significant delays in resident care and services.
Inappropriate Catheter Care Leading to Potential Infection Risk
Penalty
Summary
The facility failed to ensure appropriate care of an indwelling urinary catheter for a resident with moderate cognitive impairment and multiple diagnoses, including urinary retention and urinary tract infection. Observations revealed that the resident's catheter drainage bag and tubing were frequently positioned incorrectly, either resting on the floor or placed above the level of the bladder, which poses a risk of infection and backflow of urine. Certified Nurse Aides (CNAs) were observed placing the drainage bag on the resident's lap or hooking it under the wheelchair seat, allowing the tubing and bag to drag on the floor. Additionally, the dark blue cover used for the drainage bag only protected the sides, leaving the bottom exposed and in contact with the floor surface. The CNAs involved were unaware of proper catheter positioning techniques to prevent contamination and infection. Further observations with a Registered Nurse (RN) confirmed that the catheter drainage bag was often left on the floor, and the RN acknowledged that this practice increases the risk of cross-contamination and infection. The Director of Nursing (DON) reported that catheter tubing and bags should never touch the floor and mentioned an incident where the resident experienced urethral trauma due to the catheter becoming dislodged. However, no accident report was completed for this incident. The facility's policy on catheter care, last revised in September 2014, emphasizes the importance of keeping the catheter tubing and drainage bag off the floor and positioned lower than the bladder to prevent catheter-associated urinary tract infections, which was not adhered to in this case.
Failure to Assess Resident's Capability for Self-Administration of Medications
Penalty
Summary
The facility failed to properly assess the mental and physical capability of a resident (R42) for self-administration of medications. R42's electronic medical record indicated a BIMS score of 15/15, showing cognitive intactness, and had medical diagnoses including muscular dystrophies, congenital stenosis and stricture of the esophagus, dysphagia, and acute bronchitis. Despite these conditions, there was no order for self-administration of medications. During medication administration, an LPN left R42 alone with medications, including a nebulizer solution and gummy vitamins, without verifying if R42 had taken all her medications or ensuring her safety while swallowing them. The LPN typically waited 10 minutes before returning to check on R42, showing a lack of concern for potential swallowing difficulties or incomplete medication intake. The Director of Nursing (DON) confirmed that there was no assessment for self-administration of medications for R42. Interviews with R42 revealed that nursing staff often left her to drink her creatine and fiber mixture on her own and allowed her to self-administer her nebulizer treatment and gummy vitamins. The facility's policy stated that residents have the right to self-administer medications if deemed clinically appropriate and safe by the interdisciplinary team, which includes a specific skilled assessment. However, this assessment was not conducted for R42, leading to a failure in ensuring the resident's safety and adherence to the facility's policies.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, resulting in potential unmet needs. Resident R23, who was admitted with diagnoses including diabetes, neuropathy, and wound treatment, experienced significant weight loss over a period of time. Despite being cognitively intact and expressing concerns about weight loss, R23's care plan lacked nutritional goals or interventions to address the weight loss. The Certified Dietary Manager acknowledged the absence of a nutritional care plan and recognized the need for dietary goals and interventions, especially given R23's wound healing process and weight loss history. Resident R9, admitted with a fracture of the right femur and heart disease, was observed to have moderate cognitive impairment. During a room visit, R9 expressed a desire for more activity options, as he did not enjoy the available activities like Bingo. The Activity Director confirmed that there was no care plan for R9's preferred activities, despite the standard practice of having an activity care plan for each resident. R9 was initially admitted for rehabilitation but was now planned to stay long-term, yet his activity preferences were not addressed in his care plan.
Failure to Update Care Plans Appropriately
Penalty
Summary
The facility failed to ensure care plans were updated and revised appropriately for two residents, resulting in care plans that did not reflect the residents' needs. Resident #5, who had severe cognitive impairment and a history of repeated falls, experienced a fall that resulted in significant injuries, including a laceration on the upper right eyebrow, bruising, and a broken nose. Despite the incident, the care plan for Resident #5 was not updated to include new interventions, such as monitoring for tangled blankets, which was identified as a contributing factor to the fall. The Director of Nursing (DON) acknowledged that the care plan should have been updated but was not, contrary to the facility's policy on care plan revisions and fall prevention protocols. Resident #39 had a catheter-related pressure wound that began as a small tear in the urethral meatus due to the catheter tubing becoming entangled in his feet while self-propelling in his wheelchair. The wound care observation revealed a significant tear through the glans of the penis, and the catheter securing device lacked a date indicating when it was last changed. The DON confirmed that there was no incident report for the initial catheter dislodgement and that the care plan did not include any focus area, goal, or planned interventions related to the catheter-related pressure wound until the day of the surveyor's observation. This omission was contrary to the facility's policy on ongoing assessments and care plan revisions. Both cases highlight the facility's failure to adhere to its policies on care plan updates and revisions, resulting in care plans that did not adequately address the residents' current conditions and needs. The deficiencies were identified through interviews, record reviews, and direct observations, underscoring the importance of timely and accurate care plan updates to ensure resident safety and well-being.
Failure to Prevent Worsening of Catheter-Associated Pressure Injury
Penalty
Summary
The facility failed to provide appropriate care to prevent the worsening of a catheter-associated pressure injury for a resident with moderate cognitive impairment and multiple medical conditions, including urinary retention and generalized muscle weakness. The resident had an indwelling urinary catheter and was dependent on staff for lower body dressing. During an observation of wound care, a significant tear was noted on the resident's penis, and it was found that the catheter securing device had not been changed or rotated as per the physician's order. The nurse responsible for the wound care did not document the wound's characteristics or measurements, only noting that the care was completed per the order on the Treatment Administration Records (TARs). The catheter securing device was supposed to be alternated between legs weekly to offload pressure, but there was no documentation indicating when it was last changed or rotated, leading to potential worsening of the wound. Further review of the resident's Medication Administration Record (MAR) and TAR revealed inconsistencies in the documentation of catheter securing device changes. The device was not changed on the scheduled date and was recorded as changed two days later without proper documentation of the location. The resident's progress notes indicated that the catheter securing device was not rotated between legs as required, and there was no documentation of assessments or tracking of the wound's healing or progression. The Director of Nursing (DON) confirmed that the wound began as a small tear due to the catheter becoming dislodged and that there was no incident report or proper documentation of the trauma. The resident's electronic medical record (EMR) showed that the catheter securing device was changed on several occasions without recording the location, and there were no assessments or measurements of the wound to track its healing. The DON reported that the wound started as a small tear from the catheter dislodgement, but there was no documentation of this incident or subsequent assessments. The lack of proper documentation and adherence to physician orders led to the deficiency in providing appropriate care to prevent the worsening of the catheter-associated pressure injury.
Failure to Implement Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely physician response to Medication Regimen Review (MRR) pharmacy recommendations and did not follow the physician orders after they were written for one resident. Resident #5 (R5) had multiple diagnoses including GERD, dementia, diabetes, major depressive disorder, and chronic kidney disease. The pharmacist performed an MRR on 12/28/2023, recommending a decrease in pantoprazole dosage due to state guidelines and Beers criteria. The physician did not respond to this recommendation until 3/14/2024, agreeing to decrease the dosage, but the order was never implemented, and the pantoprazole remained at 20 mg daily. Subsequent MRRs on 1/20/2024 and 2/25/2024 did not identify any new irregularities, despite the initial recommendation not being addressed. The Director of Nursing (DON) confirmed that the MRR signed by the physician was never written as an order and expected the pharmacist's recommendations to be signed by the physician within one week. A facility policy on MRRs was requested but not provided during the survey, and the pharmacy procedure reviewed did not include the facility process or timeframe standards.
Failure to Follow Up on Dental Services
Penalty
Summary
The facility failed to follow up on routine dental services for a resident, resulting in the resident's diet being downgraded from a regular diet to a pureed diet. The resident, who had severe cognitive impairment and multiple medical conditions including complete loss of teeth, was observed eating a pureed diet during lunch rounds. The medical record indicated that the resident's dentures were sent out for repair, but there was no follow-up appointment made to ensure the dentures were returned in a timely manner. The Director of Nursing (DON) and the Business Office Manager acknowledged that the follow-up appointment was missed due to poor communication between the dental office and the facility staff. The resident's medical record showed that an impression of her mouth was taken by the dentist, and a follow-up appointment was scheduled but never made. Progress notes indicated that the resident's diet was downgraded to pureed due to spitting food out while waiting for the dentures. The care plan was updated to reflect this change, but the lack of a follow-up dental appointment led to the resident continuing on a pureed diet. The facility's policy on dental services stated that routine and emergency dental services should be available to meet the resident's oral health needs, but this was not adhered to in this case.
Failure to Ensure Dignified Care Experiences
Penalty
Summary
The facility failed to ensure dignified care experiences for three residents, leading to a deficiency in maintaining resident dignity. One resident, who had a stroke and required substantial assistance for toileting, was left on the toilet for approximately 45 minutes during a shift change. The resident became visibly upset and had to call his brother for assistance. The Director of Nursing (DON) confirmed the incident and noted that the call light system was not adequately responded to by the staff, leading to the prolonged wait time for the resident on the toilet. Another resident with severe cognitive impairment was observed being transferred to the bathroom with a sit-to-stand mechanical lift. The Certified Nurse Aide (CNA) left the bathroom door open, exposing the resident's buttocks and pubic area to her roommate. The CNA also cleansed the resident's genital area with the door open, compromising the resident's privacy and dignity. The DON acknowledged that all residents should be provided a dignified care experience, including covering exposed body parts and closing privacy curtains and window blinds. A third resident with moderate cognitive impairment and urinary issues was found lying in bed with an open incontinence brief and no covering, while the CNA walked away to perform hand hygiene. The resident expressed discomfort and coldness, and the room's window blinds were left open, exposing the resident to the view of other residents in the courtyard. The CNA later lifted the resident to a standing position with his pants down, further compromising his dignity. The DON reiterated the importance of maintaining resident privacy and dignity during care.
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.
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