Caretel Inns Of Linden
Inspection history, citations, penalties and survey trends for this long-term care facility in Linden, Michigan.
- Location
- 202 South Bridge Street, Linden, Michigan 48451
- CMS Provider Number
- 235646
- Inspections on file
- 26
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Caretel Inns Of Linden during CMS and state inspections, most recent first.
A resident with dementia, diabetes, protein-calorie malnutrition, and other comorbidities experienced significant undocumented weight loss over several months while the facility failed to obtain consistent monthly and weekly weights as required by its own guidelines and prior orders. Nursing staff did not complete or document a change-of-condition (SBAR) assessment despite provider notes describing worsening debility, decreased PO intake, and a notable drop in weight. The resident’s care plans continued to state that only limited assistance with self-feeding was needed, even though observations and staff interviews showed the resident was a total assist for eating and drinking and had been downgraded to a pureed diet. Dietary documentation contained gaps, and the dietary care plan was not revised to reflect the significant weight loss or updated diet and appetite-related medications, resulting in delayed care and contributing to a 9.23% weight loss in seven weeks.
A resident with moderate cognitive impairment and multiple medical conditions sustained a painful right-hand skin tear in the dining room when another resident with dementia and documented combative behaviors pushed the wheelchair and forcefully grabbed the resident’s hand. Staff did not witness the incident and only responded after the injured resident called for help or was seen bleeding. The injured resident later reported feeling unsafe and confined herself to her room. The aggressor’s behavior care plan already noted combative behavior, wandering, and hitting at others, but contained only a general intervention for positive interaction and was not revised with specific measures to manage his combativeness or protect other residents after the altercation.
A resident with pain and hemiplegia experienced significant medication errors when scheduled Cyclobenzaprine (Flexeril) doses were missed because the drug was unavailable, and nursing staff did not notify the physician or obtain an alternative despite a standing order for around‑the‑clock pain management. Pharmacy records showed a 30‑day supply should have remained in use, with multiple days of doses unaccounted for, and the medication was not stocked in the backup box. During the same period, a Fentanyl patch dated several weeks earlier was found still applied to the resident’s chest even though the order for the patch had been discontinued, and the DON was unaware it remained in place. These events occurred despite facility and pharmacy policies requiring medications to be administered as ordered and procedures to address unavailable or delayed medications.
The facility failed to provide a clean and homelike environment for two residents, resulting in unclean rooms and bathrooms, and a lack of clean linens. One resident's room was cluttered with bags of clothes and towels, and both residents' bathrooms had significant staining and cleanliness issues. The facility also lacked sufficient clean towels and washcloths, and was unable to provide housekeeping and linen policies when requested.
A resident with urinary retention experienced severe abdominal pain due to the facility's failure to maintain a functional bladder scanner. The scanner was inoperable, and staff were unaware of its condition, leading to complications during a trial void order. Attempts to reinsert a Foley catheter were unsuccessful, resulting in the resident being sent to the ER. The facility's policies on equipment maintenance were not followed, as no repairs or replacements were made for the broken scanner.
A resident with severe cognitive impairment and receiving hospice services developed four facility-acquired pressure ulcers due to the facility's failure to consistently implement preventive interventions. Despite having a care plan that included an air mattress and positioning aids, the resident was often observed without these measures in place. An LPN acknowledged the presence of new pressure ulcers and stated that interventions were in place, but the ulcers still developed. The facility's policy on skin management was not fully adhered to, contributing to the deficiency.
The facility failed to ensure that three CNAs completed the required 12.0 hours of annual competency training. CNA N's records lacked quantified hours and competency assessments, CNA P's records showed only 7.58 hours of training, and CNA O had no written record of completed in-service hours. The HR Director confirmed the absence of an electronic system to track training hours.
The facility failed to secure medication carts and ensure proper labeling and storage of medications. Unattended and unlocked carts were observed, with medications lacking proper labeling and topical treatments stored with oral medications. Staff acknowledged these lapses, which contravened facility policies.
The facility failed to treat residents with dignity, as call lights were not answered promptly, leading to soiled briefs and frustration. Staff were observed using personal phones during care, and grievances were not adequately addressed. Specific cases included a resident with a call light out of reach and another left in discomfort due to delayed assistance.
The facility failed to ensure a safe and sanitary environment, with an open furnace door in a resident's room and multiple sanitation issues in the kitchen, including stagnated water, sewage odors, and a water leak. The maintenance director was unaware of these issues, and no maintenance logs were available.
The facility failed to create timely, person-centered care plans for two residents within 48 hours of admission, leading to inadequate dietary management. One resident with cancer and respiratory issues struggled with chewing and required a different diet, while another with diabetes and chronic kidney disease had unmet dietary needs despite having a dialysis care plan. These care plans were delayed by four and six days, respectively, leaving staff without necessary guidance.
A resident with obstructive sleep apnea did not have a comprehensive care plan for their CPAP machine, leading to improper maintenance. The resident reported that the CPAP mask and tubing had not been changed since admission, and there was no documentation of cleaning or maintenance. The MDS Program Director acknowledged the oversight, which was contrary to facility policy requiring individualized care plans.
A resident with limited range of motion did not receive a restorative nursing program after being discharged from therapy, despite being a good candidate. The resident's medical record lacked documentation of a restorative plan, and the facility's Director of Nursing confirmed the absence of a restorative team. Efforts to train CNAs as restorative aides were ongoing but incomplete. The facility's policy required initiation of restorative programs post-therapy discharge, but this was not followed.
The facility failed to properly store, clean, and label respiratory equipment for residents, leading to potential health risks. A resident with sleep apnea reported that their CPAP mask and tubing had not been changed, and there was no documentation of cleaning. Another resident's nebulizer was improperly stored with moisture remaining, and a third resident's oxygen tubing was not labeled or dated. The facility's policies on equipment maintenance were not followed.
A facility failed to ensure complete documentation and assessment for a resident requiring dialysis. The resident, with a right-sided permacath, had inaccurate records and care plans that did not reflect the correct dialysis access site or provide proper monitoring instructions. The Hemodialysis Communication Forms lacked necessary information about the access site, and the facility's policy did not address permacath care, focusing instead on fistulas. Interviews with the DON and RN Unit Manager revealed they were unaware of these omissions.
The facility failed to ensure daily clinical staff postings were completed and available for review from January to August 2024. The DON stated that the Staffing Report, detailing the number of RNs, LPNs, and CNAs, was to be posted daily. However, reports for July 2024 were mostly missing, and several from January and February 2024 were incomplete. The Scheduler started the forms but relied on others for completion, leading to discrepancies. The receptionist was unaware of her role in this process, resulting in missing and incomplete staffing reports.
A facility failed to obtain informed consent for an antipsychotic medication prescribed to a resident with Alzheimer's dementia and other conditions. The resident's record contained an incomplete psychiatric consultation from a previous admission, lacking specific medication consent. This oversight violated the facility's policy requiring informed consent for psychotropic medications.
A resident with severe cognitive loss was sexually abused by another resident with moderate cognitive impairment. Despite a history of wandering and inappropriate behavior, there were no care plans or physician orders to address the behavior. The facility's intervention of hourly checks was ineffective, and documentation failed to reflect the resident's behavior, contributing to the incident.
A resident experienced a fall and subsequent spinal injury, but the facility failed to retain complete documentation and conduct a thorough investigation. The incident report was incomplete, lacking critical information, and the facility's investigation did not include necessary interviews or documentation to support conclusions. The Director of Nursing and Administrator acknowledged the deficiencies in the investigation and documentation process.
Two residents experienced delays in nutritional assessments and care planning, with inconsistent documentation of meal intake. One resident had difficulty chewing, and the other required dialysis, increasing nutritional risk. The facility failed to address these needs promptly, leading to deficiencies in care.
A facility failed to follow physician's orders and policy for enteral feeding for a resident with severe cognitive impairment, resulting in the resident not receiving the prescribed amount of feeding. The feeding was administered at a lower rate than ordered, and there was no documentation of the total intake. The DON acknowledged the rate was reduced due to nausea but lacked a system for documenting intake when adjustments were made.
A resident with lung cancer and metastasis experienced unrelieved pain due to the facility's failure to promptly assess and manage pain effectively. The resident's family reported ineffective pain medication and delays in processing new orders. The resident was given Tylenol, which did not alleviate the pain, and later received Morphine and Lorazepam simultaneously, which was too sedating. The care plan was delayed, and the facility did not adhere to its policy on resident rights.
Two residents in an LTC facility did not receive their prescribed medications due to unavailability. A Lidocaine Patch and Lantus insulin were not administered as ordered, resulting in a medication error rate of 6.25%. The facility's policy requires timely administration, but the medications were not in stock or delivered on time.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.25% error rate. Two residents did not receive their prescribed medications due to unavailability: one missed a Lidocaine patch, and the other missed a Lantus insulin injection. The nurse and DON were aware of the issues, which were attributed to stock shortages and recent admission delays.
A resident in an LTC facility did not receive their prescribed Lantus insulin due to unavailability, and there was a route error in the insulin order. Additionally, the resident's pain level was not assessed before administering Tylenol, despite an active order for Norco for severe pain. The DON acknowledged the medication unavailability due to the recent admission.
A facility failed to ensure proper documentation of hospice services for a resident with severe cognitive impairment, resulting in missing progress notes in the medical record. Despite being admitted to hospice care months earlier, the most recent note was from over two months prior. Staff interviews revealed that the hospice company was new to the facility and had not been sending updates as frequently as expected.
Failure to Monitor Weight, Document Change of Condition, and Update Care Plan for Resident With Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to monitor a resident’s weight per orders and facility guidelines, failure to complete and document a change-of-condition assessment when significant weight loss occurred, and failure to update the resident-centered care plan to reflect current needs. The resident had multiple diagnoses including protein-calorie malnutrition, diabetes, GERD, bipolar disorder, dementia, and hypertension, and was cognitively impaired with a BIMS score of 10/15, requiring assistance with care. Weight records showed gaps and significant losses: no weights documented for November 2025 and January 2026, a 5.82% loss between late October and late December 2025, and a 9.23% loss between early February and late March 2026. Despite facility guidelines requiring monthly weights and weekly weights with significant change or decline in intake, there were no current weight orders beyond an older weekly-weight order from 10/7/2024, and the DON could not account for the missing monthly weights. The facility also did not complete or document a change-of-condition assessment (SBAR or equivalent nursing assessment) in response to the resident’s significant weight loss. Provider notes in March 2026 documented worsening debility, decreased oral intake (approximately 25–50% of meals and sometimes 0%), and a documented weight drop from 143 lbs to 129.8 lbs. The PA ordered the resident to be weighed and referenced weight concerns on multiple dates, but there were no SBAR forms or nursing notes documenting a change-of-condition assessment related to the weight loss. The DON confirmed that such weight changes would be considered a significant change, that a change-of-condition assessment should have been completed, and that SBAR is the facility’s method for documenting such changes, yet none were found in the medical record. Although medical providers and dietary staff later documented weight loss and interventions, the nursing documentation of assessment and change-of-condition response was absent. In addition, the resident’s care plans were not updated to reflect current nutritional risk, weight loss, and ADL/feeding status. The bedside and nursing care plans continued to state that the resident needed only limited assistance with self-feeding using adaptive equipment, even though direct observations and staff interviews showed the resident was a total assist for eating and drinking and could not coordinate holding a cup. CNA and nurse interviews confirmed that the resident required feeding assistance and had been a total feed since therapy ended, but this was not reflected in the care plan. The dietary care plan, originally created in October 2024 and revised in January 2026, identified the resident as at risk for malnutrition and outlined monitoring for significant weight changes, but there were no further revisions to incorporate the documented significant weight loss, diet texture changes, or appetite-related medication orders. Dietary progress notes also showed gaps, with no notes between late October 2025 and late February 2026, and then none again until April 2026, despite the resident’s documented weight loss and risk for malnutrition. These combined failures resulted in delayed care contributing to a 9.23% weight loss over seven weeks. The deficiency was further illustrated by inconsistencies between practice and documentation. Observations on the survey date showed the resident in bed after breakfast with staff unable to state how much she had eaten, and later being totally fed 100% of a pureed lunch by a CNA. Staff interviews indicated that the resident had been eating better since a recent change to a pureed diet and that she could not feed herself, yet the care plan still described only limited assistance. The RD reported that she was on maternity leave during part of the period when weights and dietary notes were missing and was unaware of the December weight loss, stating that another RD should have addressed it. The DON acknowledged that the care plan did not reflect the resident’s current ADL and dietary needs, that there were no documented weekly weight orders despite RD and provider requests, and that there was no additional documentation to support appropriate monitoring and response to the resident’s significant weight loss. Overall, the facility’s inactions and documentation gaps—missing monthly and weekly weights, lack of change-of-condition assessment and nursing notes, and failure to revise the care plan to reflect total feeding assistance and significant weight loss—resulted in delayed care for a resident with known malnutrition risk and contributed to a 9.23% weight loss in seven weeks.
Failure to Protect Resident From Abuse and Inadequate Behavior Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident in the dining room. On the date of the incident, a female resident seated in her wheelchair in the dining room was approached by another resident who began pushing her wheelchair. The seated resident extended her right hand and asked the other resident to stop, at which point the other resident grasped the top of her right hand, causing a skin tear on the dorsal right hand. During the same timeframe, the aggressor resident was also observed on camera grabbing and shaking other residents’ wheelchairs in the dining area. Seven staff members later stated they did not witness the actual altercation and only became aware when the injured resident called for help or was observed bleeding. The injured resident had a history of generalized muscle weakness, need for assistance with personal care and ambulation, major depressive disorder, and type 2 diabetes, with a BIMS score indicating moderate cognitive impairment. She reported to the surveyor that a man in the building had “stabbed” her hand by digging his fingers between her thumb and index finger, and she stated that she did not feel safe and was staying in her room because that was where she felt safe. During a subsequent joint visit with the social worker and surveyor, she again expressed anger that the man was still “roaming the facility,” stated she felt unsafe outside her room, and said she had a plan to fight back if he came near her. Wound assessments documented a painful right-hand skin tear with sanguinous/serosanguinous drainage that persisted over multiple assessments. The resident who caused the injury had diagnoses including dementia, psychotic disorder with delusions, mood disorders, generalized anxiety disorder, and type 2 diabetes. His behavior care plan, initiated months earlier, documented that he could be combative, wander into other residents’ rooms, and hit out at other residents. The care plan goal was that he would have no evidence of behavior problems, with an intervention for caregivers to provide opportunities for positive interaction when passing by. Although the care plan showed a revision date after the altercation, it did not add any specific interventions to address his combativeness or to protect other residents from harm, and the behavior care plan was not updated following the resident-to-resident altercation. This failure to revise and individualize the behavior care plan, in the context of known behavioral risks and an actual physical altercation resulting in injury, constituted the cited deficiency in protecting residents from abuse.
Significant Medication Errors Involving Flexeril and Fentanyl Patch
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to both a scheduled muscle relaxant (Cyclobenzaprine/Flexeril) and a Fentanyl patch. During a medication pass observation, the nurse reported that the resident’s Flexeril was not available for the 1:00 PM dose and that it had also been unavailable for the 5:00 AM dose that same day. The nurse stated she had learned from the night shift that the last Flexeril dose was given the previous evening and that the pharmacy had reported it was too early to refill, with the next delivery not due until later in the month. The medication was not available in the emergency backup box, and the nurse did not notify the physician on call when the doses were missed. The resident had diagnoses including pain, anxiety disorder, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and depression, and had an opioid pain management care plan. The physician later confirmed that neither he nor his associates had been informed about the missed Flexeril doses and stated that missing a scheduled pain-relief medication without physician notification constituted a medication error. Pharmacy records showed that a 30‑day supply of Flexeril had been dispensed and should have lasted until a later date, indicating approximately nine days’ worth of doses (27 tablets) were unaccounted for. The DON acknowledged that the Flexeril was unavailable, that two doses were missed on the day of the survey, and that no provider had been notified when the medication first ran out. A second medication error was identified when a Fentanyl patch was observed on the resident’s chest, dated several weeks earlier, despite there being no current physician order for the patch. The resident requested its removal, stating it had been in place for weeks. Upon review, the DON confirmed that the Fentanyl patch order had been discontinued several weeks prior, yet the patch remained on the resident’s body and had not been removed at the time of discontinuation. The consultant pharmacist confirmed there was no active order for the Fentanyl patch and that it should have been discontinued, and also explained that Flexeril was not stocked in the backup box because the facility had not requested it and that early refills required facility authorization. Facility policies reviewed required that medications be administered as prescribed and that procedures be in place for when medications are delayed or unavailable, but these were not followed in this case, resulting in the identified medication errors.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by the conditions observed in the rooms of two residents. Resident #1, who was admitted with multiple diagnoses including dementia and schizophrenia, was found in a room cluttered with large bags of clothes and towels, some of which were not identified as belonging to the resident. The bathroom in Resident #1's room was observed to be unclean, with orange-brown stains in the toilet bowl and yellow stains on the floor beneath the sink. Additionally, there was a lack of clean towels and washcloths available for resident use, as noted during a tour of the facility's laundry and linen storage areas. Resident #5, who had severe cognitive deficits and required assistance with all care, was found to have a bathroom with a large dark orange stain in the sink and similar stains in the toilet. The floor was also soiled with yellow stains, and an unlabeled bedpan was left on a commode chair. The facility was unable to provide a housekeeping policy for daily cleaning or a linen policy when requested. The administrator acknowledged staff turnover in the housekeeping and maintenance departments, which may have contributed to the deficiencies observed.
Failure to Maintain Bladder Scanner Leads to Resident Complications
Penalty
Summary
The facility failed to maintain essential equipment, specifically the bladder scanner, in good repair, which was necessary for assessing residents with urinary retention. This deficiency was identified during the review of a resident who had been diagnosed with urinary retention, elevated PSA, chronic kidney disease, and chronic respiratory failure. The resident was on a trial void order, which required the use of a bladder scanner to monitor urinary retention. However, the scanner was found to be inoperable, and staff were unaware of its condition until it was needed. On the day of the incident, the resident experienced severe abdominal pain, and staff were unable to measure urinary retention due to the broken bladder scanner. Despite attempts to reinsert a Foley catheter, the procedure was unsuccessful, and blood clots were observed, prompting the need to send the resident to the emergency room for catheter reinsertion. Interviews with nursing staff and the nurse practitioner revealed that the bladder scanner's malfunction was not reported or addressed in a timely manner, leading to complications in the resident's care. The Director of Nursing and the Administrator were both unaware of the bladder scanner's condition until after the incident. The Administrator admitted that no attempts were made to repair or replace the equipment, despite its critical role in resident care. The facility's policies on equipment maintenance and bladder scanner usage were reviewed, highlighting the expectation for timely repairs and the provision of backup devices, which were not followed in this case.
Failure to Prevent Facility-Acquired Pressure Ulcers
Penalty
Summary
The facility failed to implement and carry out interventions to prevent the development of pressure ulcers for a resident, resulting in the development of four facility-acquired pressure ulcers. The resident, who is severely cognitively impaired and receiving hospice services, was observed with multiple pressure ulcers, including those on both elbows and the left and right iliac crest, which were identified as facility-acquired. The care plan for the resident included interventions such as an air mattress, wedge for positioning, and offloading of heels, but these were not consistently implemented, as observed during the survey. The resident was frequently observed lying on their back without the necessary positioning aids, such as a wedge cushion, and with inconsistent use of elbow protectors. The LPN interviewed acknowledged the presence of new pressure ulcers and stated that interventions like turning the resident every two hours and using elbow guards were in place, but the pressure ulcers still developed. The LPN also mentioned the completion of an Unavoidable Skin Condition Form, which was not initially found in the electronic medical record. The facility's policy on skin management outlines the need for a comprehensive care plan addressing risk factors, preventative devices, and regular evaluation of pressure injuries, which was not fully adhered to in this case.
Deficiency in CNA Annual Competency Training
Penalty
Summary
The facility failed to maintain the required annual-based competencies and education of 12.0 hours for three Certified Nursing Assistants (CNAs) reviewed. CNA N, hired in 2013, had an in-service training record that did not specify the number of hours attended, lacked competency assessments, and had no validation of lessons by the instructor. Similarly, CNA P, hired in 2023, had education checklists without quantified in-service minutes or competency assessments. CNA O, recently hired, had no written record of in-service hours completed during orientation. The Human Resources Director acknowledged the absence of an electronic learning system to track training hours and records for each staff member. Although an electronic tracking record for CNA P was later submitted, it showed only 7.58 hours of training, falling short of the required 12.0 hours. No records were provided for CNAs N and O. The facility's policy mandates maintaining individual in-service logs and ensuring evaluations for each in-service, which was not adhered to in these cases.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper labeling of medication carts and treatment carts, as well as the appropriate storage of medications. On multiple occasions, medication carts were observed unlocked and unattended, with no nurse in the vicinity. This included a treatment cart in the 300-hall entrance and dining area, and a medication cart in the 300 Hall, which was left unlocked with resident information exposed on the computer screen. Additionally, medications such as Fluticasone nasal spray and Artificial Tears were found without proper labeling, lacking resident identification and open dates. Glucose monitoring test strips were also found open and undated. Furthermore, the facility did not adhere to its policy of separating topical treatments from oral medications. Topical creams such as capsaicin, hydrocortisone, and estradiol were stored alongside oral medications and breathing treatments in the medication cart, contrary to facility policy. The staff acknowledged these lapses, with nurses indicating that the carts should be locked and medications properly labeled and stored. The facility's policies, dated November 2021, clearly state that medication carts should be locked when not attended and that oral and topical medications should be stored separately.
Deficiencies in Resident Care and Dignity
Penalty
Summary
The facility failed to ensure that residents were treated in a respectful and dignified manner, as evidenced by multiple observations and interviews. Residents reported that call lights were not answered in a timely manner, with some waiting up to 45 minutes to an hour for assistance, particularly for toileting needs. This delay in response led to residents experiencing soiled briefs and feelings of frustration, anger, and embarrassment. Additionally, call lights were often found out of reach, preventing residents from being able to summon help when needed. Further issues were identified with staff behavior, as residents reported that staff members were frequently observed talking on personal cell phones while providing care. This behavior was noted to be disrespectful and intrusive, as residents could overhear personal conversations. The facility also failed to adequately address grievances raised by residents, with reports indicating that grievances were not consistently followed up on, leaving residents feeling unheard and disrespected. Specific cases highlighted in the report include Resident #20, who was found with a call light on the floor, out of reach, and Resident #41, who experienced extended wait times for assistance, resulting in discomfort and pain. Resident #41 also reported an incident where she fell over in bed and was left in that position without assistance. These deficiencies reflect a broader issue of inadequate staffing and resource allocation, as evidenced by the lack of sufficient housekeeping and laundry services, leading to unclean hallways and delayed laundry returns.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in both resident care areas and the kitchen, potentially affecting all 55 residents. In one instance, a door leading to a furnace and piping in a resident's room was found open and could not be closed by housekeeping staff, posing a safety risk. The maintenance director later confirmed that the door was left open after a pest control inspection and was unaware it had not been shut or locked. Additionally, the main dining room floor was observed to be sticky, and a resident's room had a strong smell of urine with stained carpet, indicating a lack of cleanliness. In the kitchen, several issues were identified, including stagnated water with a sewage smell under the three-compartment sink, a non-functional chemical treatment machine, and drain flies. Another drain emitted a strong sewage odor and was not in use, while a third drain had a water leak causing a puddle on the floor. The maintenance manager was unaware of the leak, and no maintenance logs or records were available for review. These deficiencies highlight significant lapses in maintaining a sanitary environment, which could lead to foodborne illnesses and dissatisfaction with living conditions.
Failure to Implement Timely Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a person-centered baseline care plan within 48 hours of admission for two residents, resulting in inadequate guidance for staff to provide effective care. Resident #307, who was admitted with multiple serious health conditions including cancer and respiratory issues, was observed having difficulty chewing and required a different textured diet. However, the care plan addressing his nutritional needs was not created until four days after admission, leaving staff without necessary instructions to address his immediate dietary needs. Similarly, Resident #308, who had complex medical conditions including diabetes and chronic kidney disease requiring dialysis, did not have a care plan addressing his dietary needs until six days post-admission. Although a dialysis care plan was in place, it lacked any mention of dietary requirements. This delay in care planning resulted in the absence of specific instructions for staff to manage his nutritional intake effectively, as evidenced by his partially eaten meal and non-verbal dissatisfaction with his breakfast.
Failure to Implement CPAP Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident's use and maintenance of a CPAP machine. The resident, who was admitted with diagnoses including diabetes, weakness, and obstructive sleep apnea, was observed using a CPAP machine that was not properly maintained. The resident reported that the CPAP mask and tubing had never been changed since their admission, and there was no documentation in the medical record regarding the cleaning of the CPAP or the replacement of its components. Additionally, the care plan for the resident did not include any information about the use and maintenance of the CPAP machine. The resident, who had moderate cognitive impairment, indicated that they had long used a CPAP machine and were aware of the need for regular maintenance, such as changing the mask every 30 days. Despite the resident's awareness and requests for the mask to be changed, the facility did not address these needs. An interview with the MDS Program Director confirmed that a care plan for the CPAP should have been in place, but it was missed. The facility's policy requires that each resident have a current and individualized care plan developed within seven days of arrival, which was not adhered to in this case.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to implement a restorative nursing program for a resident with limited range of motion, resulting in the potential for decline in independence and physical ability. The resident, who was cognitively intact, had impairments in both lower extremities and required varying levels of assistance with daily activities. Despite being discharged from physical and occupational therapy with a home exercise program, there was no documentation of a restorative therapy plan or program in the resident's medical record. Interviews with the resident revealed that she was unaware of any restorative therapy plan following her physical therapy. The Director of Nursing confirmed the absence of a restorative team and mentioned ongoing efforts to train CNAs to become restorative aides, although the training had not been completed. The Therapy Program Manager acknowledged that the resident was a good candidate for a restorative therapy program and that such a program would not hinder her access to future therapy services. The facility's policy on restorative nursing programs indicated that such programs should be initiated when a resident is discharged from formalized rehabilitation therapy. However, the policy was not followed, as evidenced by the lack of a restorative program for the resident. The Administrator noted that the restorative therapy program had been discussed in a quality assurance meeting, but it had not yet been implemented.
Improper Respiratory Equipment Management
Penalty
Summary
The facility failed to ensure proper storage, cleaning, and labeling of oxygen and respiratory equipment for several residents, leading to potential health risks. Resident #23, who has moderate cognitive impairment and uses a CPAP machine for obstructive sleep apnea, reported that the CPAP mask and tubing had not been changed since admission, and there was no documentation of cleaning or maintenance. The resident indicated that the CPAP machine was provided by the facility, and the Director of Nursing (DON) confirmed that there was no batch order for cleaning, which should have been documented. Resident #34, who is cognitively intact and has chronic obstructive pulmonary disease, was observed with a nebulizer that had moisture and liquid remaining in the medication chamber, indicating improper cleaning and storage. The resident's family member was unsure about the frequency of nebulizer use, and the DON acknowledged that nebulizer equipment should be cleaned and dried before storage to prevent mold growth. The facility's policy requires nebulizer equipment to be washed and air-dried completely before storage, but this was not followed. Resident #9, who has severe cognitive impairment and uses oxygen therapy, was observed with oxygen tubing that was not labeled or dated. The resident was seen using a portable oxygen tank, and the oxygen concentrator tubing was found in a bag without a date. The DON and a registered nurse both indicated that the tubing should be labeled and dated according to facility policy, which was not adhered to. The facility's policy mandates that oxygen delivery devices be changed weekly and stored in a clean bag when not in use, but these procedures were not followed for Resident #9.
Incomplete Dialysis Documentation and Assessment
Penalty
Summary
The facility failed to ensure complete and accurate documentation and assessment for a resident requiring dialysis care. Resident #308, who has multiple diagnoses including chronic kidney disease and requires renal dialysis, was admitted with a right-sided permacath for dialysis. However, the facility's records, including physician orders and care plans, did not accurately reflect the resident's dialysis access site or provide appropriate monitoring instructions. The care plan incorrectly mentioned a graft or fistula instead of the permacath IV catheter, and there was no mention of the permacath in the care plan to prevent adverse events. Additionally, the Hemodialysis Communication Forms for the resident lacked information about the dialysis access site, which is crucial for monitoring potential adverse effects or infections. The facility's policy on dialysis care did not address the specific needs of residents with a permacath, focusing instead on fistulas. Interviews with the Director of Nursing and RN Unit Manager revealed that they were unaware of the omission and planned to investigate further. The hospital discharge instructions, which included keeping the permacath clean and dry, were not incorporated into the facility's plan of care.
Deficiency in Daily Clinical Staff Postings
Penalty
Summary
The facility failed to ensure that clinical staff postings were completed and available for review for multiple days from January 2024 to August 2024. This deficiency was identified through observation, interview, and record review. The Director of Nursing (DON) stated that the Clinical Staff posting document, known as the Staffing Report, was supposed to be completed daily by the Scheduler and posted on the wall by the nurses' desk. This document was intended to show the number of RNs, LPNs, and CNAs staffed each day, along with the total hours worked per shift and the resident census. However, upon review, it was found that the daily reports for July 2024 were missing, except for one day, and several documents from January and February 2024 were also missing or incomplete, lacking staff hours and census data. The Scheduler D explained that she started the forms with information from the nurses' schedule and then sent them to the nursing supervisor. On days she was not working, she would send the documents in advance to the receptionist for completion. However, the receptionist stated she did not handle these forms and was unaware of their contents. The Scheduler D acknowledged that some forms were incomplete and could not locate the missing staffing forms from July 2024. The facility's policy on the assignment of nursing care, which was reviewed and revised in August 2024, required nursing assignments to be based on the number of staff on the units, but this was not adhered to due to the incomplete and missing staffing reports.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent for the use of an antipsychotic medication for a resident, resulting in the potential for the administration of unnecessary medication. The resident, who was readmitted to the facility with multiple diagnoses including Alzheimer's dementia, depression, and anxiety, was prescribed Risperdal, an antipsychotic medication, without documented consent. A psychiatric consultation from a previous admission was found in the resident's record, but it did not specify any medications or provide clear consent for the current treatment. The facility's policy requires that residents or their responsible parties be informed of the risks and benefits of psychotropic medications and that informed consent be documented in the medical record. However, the documentation for this resident was incomplete and did not meet the facility's policy requirements. This oversight in obtaining and documenting informed consent for psychotropic medication use highlights a deficiency in the facility's medication management process.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, as evidenced by an incident involving two residents. Resident #59, who had severe cognitive loss and required supervision with mobility, was found in her room with Resident #309, who had moderate cognitive impairment. Resident #309 was discovered by a CNA with his hand down Resident #59's pants. The CNA immediately intervened and reported the incident to the nurse and the administrator. The investigation revealed that Resident #309 had a history of wandering and had previously been involved in a consensual relationship with another resident. Despite this history, there were no care plans or physician orders in place to address Resident #309's wandering or sexually inappropriate behavior. The facility's intervention of implementing hourly checks was ineffective in preventing Resident #309 from entering female residents' rooms. The facility's documentation, including progress notes and social services assessments, failed to accurately reflect Resident #309's behavior. The discharge planning review did not mention Resident #309's sexually inappropriate behavior, and the facility's abuse reporting policy did not address resident-to-resident abuse. This lack of documentation and planning contributed to the failure to protect Resident #59 from abuse.
Incomplete Documentation and Investigation of Resident Fall
Penalty
Summary
The facility failed to retain documentation regarding an injury after a fall investigation for a resident, resulting in missed opportunities to prevent potential abuse or neglect. The incident involved a resident who was found on the floor by a CNA, attempting to leave the facility. The initial incident report was incomplete, with unchecked boxes and missing pertinent information, such as pain level and mental status. The resident was later diagnosed with an acute traumatic injury of the spine, which was not documented in the facility's investigation. The Director of Nursing (DON) acknowledged the incompleteness of the incident report and attributed it to an agency nurse who was responsible for filling it out. The DON, who was new to the position at the time, did not recall many details of the incident. The facility's investigation lacked interviews, staff involvement lists, and written statements, and there was no documentation to support the conclusion that neglect was not substantiated. The facility's policy required retention of internal investigation reports for four years and nursing incident reports for three years, but the documentation for this incident was not retained. The facility's Falls Management Guideline emphasized the importance of reviewing and updating the resident's plan of care following a fall, but this was not done in this case. The Administrator confirmed the investigation was incomplete and should have been retained, especially since it was reported to the State Agency.
Delayed Nutritional Assessments and Monitoring
Penalty
Summary
The facility failed to ensure timely interventions to promote nutrition for two residents, resulting in a lack of timely assessments and monitoring of their nutritional needs. Resident #307 was admitted with multiple serious diagnoses, including cancer and respiratory failure. Despite the family's concerns about the resident's difficulty chewing and the need for a different textured diet, the facility did not accurately document the resident's food intake or address the chewing problem until four days after admission. The initial dietary assessment and care plan were delayed, and the resident's nutritional needs were not promptly addressed. Resident #308, who was admitted with conditions such as diabetes and chronic kidney disease requiring dialysis, also experienced delays in nutritional assessment and care planning. The resident's dietary preferences were not assessed until five days after admission, and there was inconsistency in documenting meal intake. The resident was not eating well, and the facility did not consistently monitor his nutritional needs, despite the increased risk due to dialysis. The dietary profile and care plan were completed six days after admission, indicating a significant delay in addressing the resident's nutritional requirements. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, including participating in care planning. However, the delayed assessments and inconsistent documentation of meal intake for both residents indicate a failure to adhere to this policy. The lack of timely intervention and monitoring of nutritional needs for these residents highlights deficiencies in the facility's processes for ensuring adequate nutrition and care planning.
Failure to Follow Enteral Feeding Orders and Document Intake
Penalty
Summary
The facility failed to adhere to physician's orders and facility policy regarding enteral feeding for a resident with severe cognitive impairment and multiple medical conditions, including dysphagia and cerebral infarction. The resident was observed receiving enteral feeding at a rate of 50ml/hr, contrary to the physician's order of 60ml/hr for 16 hours. This discrepancy resulted in the resident not receiving the total ordered amount of 960ml of enteral feeding. Additionally, there was a lack of documentation regarding the total amount of enteral feeding infused, as the facility's Medication Administration Record (MAR) only indicated the start and stop times of the feeding. The Director of Nursing (DON) acknowledged that the feeding rate had been reduced due to the resident experiencing nausea, but there was no system in place for staff to document the total intake when the rate was adjusted. The facility's policy on enteral tube care and maintenance requires the pump to be cleared at the end of each shift after documenting the total amount infused, which was not followed. The DON assumed that the resident was receiving the total ordered amount based on staff signing off on the order, despite the lower infusion rate and lack of documentation.
Inadequate Pain Management for Resident with Cancer
Penalty
Summary
The facility failed to provide adequate pain management for a resident with a history of lung cancer with metastasis to the liver and bone, pulmonary edema, respiratory failure, pneumonia, and glaucoma. Upon admission, the resident was not promptly assessed or provided with effective pain relief, resulting in the resident experiencing significant pain and discomfort. The resident's family reported that the pain medication provided was not effective, and there was a delay in processing new medication orders from the physician. The resident was initially given Tylenol, which did not adequately manage the pain, as indicated by the resident's pain rating of 10 on a 0-10 scale. Further complications arose when the resident was administered Morphine and Lorazepam simultaneously, which the family and resident found too sedating. The facility's care plan for the resident was not initiated until two days after admission, despite the resident's high risk for pain due to their medical condition. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, and allowing them to participate in care planning, which was not adhered to in this case.
Medication Unavailability Leads to Errors
Penalty
Summary
The facility failed to ensure that medications were available and administered timely as ordered for two residents, resulting in medication errors. During a medication administration observation, it was noted that a Lidocaine 4% Patch for one resident and Lantus insulin for another resident were unavailable. The Lidocaine Patch was not in stock, and no backup supply was available, leading to a delay in administration. The insulin was unavailable because the resident had just been admitted, and the medication had not yet been delivered by the pharmacy. The Director of Nursing confirmed that the Lidocaine Patch was reordered three days prior but was not delivered as expected. The insulin was not available in the backup medication supply, and the pharmacy had not restocked it. The facility's policy requires medications to be administered as prescribed, but the unavailability of these medications led to a medication error rate of 6.25% during the observation period. The failure to provide these medications as ordered resulted in potential adverse reactions for the residents involved.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 6.25% error rate during a medication administration observation. This deficiency was identified when two medications were omitted for two residents. The first resident, who was cognitively intact with a BIMS score of 15/15, did not receive their prescribed Lidocaine 4% patch due to its unavailability in the facility. The nurse attempted to locate the patch in the stock/storage medication rooms but found none available and informed the Director of Nursing (DON) about the situation. The patch was reordered three days prior but was not delivered as expected. The second resident, admitted with multiple diagnoses including diabetes mellitus, did not receive their scheduled Lantus insulin injection because it was unavailable. The nurse discovered the absence of the insulin while preparing the resident's medication and was unable to find it in the backup kiosk. The DON explained that the insulin was unavailable due to the resident's recent admission and the pharmacy's delay in restocking. Both incidents contributed to the facility's medication administration error rate exceeding the acceptable threshold.
Medication Errors and Pain Management Deficiency
Penalty
Summary
The facility failed to prevent significant medication errors for a resident, resulting in the potential for serious adverse effects. The resident, who was recently admitted with multiple diagnoses including diabetes mellitus and vertebrogenic low back pain, did not receive their prescribed Lantus insulin injection due to its unavailability. Nurse K, responsible for administering the medication, was unable to locate the insulin in the backup medication supply and did not administer it as scheduled. Additionally, there was an error in the medication order for Insulin Glargine, which incorrectly stated to administer it by mouth, indicating a route error. Furthermore, during the morning medication pass, Nurse K did not assess the resident's pain level before administering a single tablet of Tylenol, despite the resident expressing a pain level of 6 out of 10 and a preference for stronger pain relief. The resident had an active order for Norco for moderate to severe pain, which was not considered. The Director of Nursing acknowledged the unavailability of the Lantus insulin due to the recent admission, and the facility's policy was reviewed, highlighting the need for proper medication administration and availability.
Failure to Document Hospice Services
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in the absence of progress notes in the medical record. The resident, who is severely cognitively impaired and receiving hospice services, was admitted to the facility with diagnoses including dysphagia, cerebral infarction, traumatic brain injury, and pressure ulcers. A record review revealed that the most recent hospice note in the electronic medical record was from over two months prior, despite the resident being admitted to hospice care several months earlier. Interviews with facility staff, including the medical records personnel and the Director of Nursing, confirmed the lack of recent hospice documentation. The medical records staff acknowledged that the hospice company involved was new to the facility and had not been sending notes as frequently as other companies, which typically provide updates within a week. The Director of Nursing stated that the goal is to receive progress notes weekly, aligning with the facility's policy that emphasizes regular communication and documentation from hospice agencies.
Latest citations in Michigan
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
