Cascade Senior Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Michigan.
- Location
- 2121 Robinson Road, Jackson, Michigan 49203
- CMS Provider Number
- 235574
- Inspections on file
- 23
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Cascade Senior Care Center during CMS and state inspections, most recent first.
A resident admitted with malnutrition, postprocedural complications, digestive system disorders, and an abdominal surgical wound, and who was cognitively intact per MDS, did not receive assistance with showers or bed baths for 11 days after admission. A family member reported the resident did not receive showers and was often found soiled with urine and not cleaned up for the day. Facility shower logs confirmed no bathing occurred during this period, and progress notes showed no documented refusals. The DON stated that residents are expected to receive showers twice weekly and that refusals are to be documented in the EMR, but could not explain the lack of bathing for this dependent, post-surgical resident.
A resident with intact cognition and multiple medical conditions, including malnutrition and postprocedural digestive complications, sustained bilateral calf skin tears during a transfer back to bed. The resident reported her legs were pushed against the bedframe, causing pinching and pain, and bleeding was later observed. Documentation showed the resident was non-ambulatory and required 2PA for transfers with an EZ stand, but interviews revealed that only one CNA performed the transfer and that the second staff member present was not assisting. There were conflicting accounts about whether a mechanical lift was used, and the injury was believed to have occurred when loose skin was pinched between the bedframe and transfer equipment.
The facility failed to ensure staff consistently used required PPE for Contact precautions. A resident on Contact precautions for diarrhea, with moderately impaired cognition and diagnoses including malnutrition and Type 2 DM, had a Contact precautions sign posted, yet CNAs repeatedly entered and exited the room wearing only surgical masks and without gowns or gloves, despite acknowledging that gowns and gloves were required. A PPE cart near the room lacked gloves, and the resident reported staff did not wear gowns and usually only wore gloves. A laundry aide was also observed entering multiple rooms, including a Contact precautions room, without hand hygiene and without donning additional PPE. These practices were inconsistent with the facility’s policy and stated expectations that staff wear gowns and gloves and don PPE upon room entry and discard it before exiting.
The facility did not follow required procedures for timely reporting of an alleged abuse incident involving two cognitively impaired residents. After one resident accused a staff member of attempted rape during care, the incident was not reported to the State Agency within the mandated two-hour timeframe, despite facility policy requiring immediate reporting.
Two residents with end-stage renal disease did not receive proper medication management, accurate documentation, or adherence to physician orders regarding dialysis schedules and weight monitoring. One resident missed multiple doses of a prescribed medication, had altered dialysis days without physician notification, and experienced significant weight loss without intervention or dietician oversight. Another resident missed a dialysis session due to missing equipment, with no documentation or physician notification. Required assessments and communication forms were also missing.
Two residents requiring dialysis did not have proper documentation of dialysis communication, physician notification, or weights when their dialysis schedules were altered or missed. One resident was not sent with required equipment, resulting in an incomplete dialysis session, and staff could not explain or justify changes to the dialysis schedule.
A resident with end-stage renal disease and hyperphosphatemia did not receive any doses of a prescribed medication, Sevelamer HCl, because it was not available in the facility. Despite this, the MAR inaccurately indicated that some doses were administered. The DON confirmed the medication was never in-house, and the family was only informed after several days. The resident was later transferred to a hospital due to a change in condition.
A deficiency was cited for failing to address certain general requirements under LSC Sections 18.1 and 19.1 that were not covered by the existing K-tags. The report does not specify the exact actions or omissions involved.
A resident with a history of respiratory failure and other chronic conditions was admitted from the hospital with ongoing hypoxia and required respiratory support. After reporting difficulty breathing and requesting a change from CPAP to oxygen via nasal cannula, the resident was not assessed by a licensed nurse, and as-needed inhaled medications were not administered. The resident was later found unresponsive and pronounced deceased, with staff interviews confirming a lack of follow-up assessment after the report of respiratory distress.
The facility did not consistently respond to resident call lights in a timely manner, with multiple residents experiencing wait times ranging from 15 minutes to two hours for assistance with personal care and toileting. Documentation and resident interviews confirmed repeated delays, particularly during shift changes, and some residents reported episodes of incontinence as a result.
The facility did not provide timely and accurate NOMNC and SNF ABN forms to two residents, with both notices being signed either one day before or on the last covered day, rather than within the required advance notice period. The social worker responsible for issuing these notices was unable to explain the delay or inaccuracy.
A resident with multiple medical and cognitive conditions did not have a comprehensive care plan addressing activity preferences, resulting in boredom and lack of awareness of available activities. The resident's records lacked documentation of activity preferences, and staff interviews confirmed that expected practices for care planning and activity calendar distribution were not followed.
A resident with moderate cognitive impairment and multiple medical conditions was not provided with meaningful, individualized activities. The resident reported boredom, was unaware of any activity calendar, and had not been invited to participate in activities. Review of records showed no care plan for activity preferences and only solitary activities documented, with no evidence of group activities being offered.
Two residents were found with medications at their bedside without required assessments, physician orders, or care plans for self-administration, and an opened multi-dose vial in the medication room refrigerator was not dated as required. Staff confirmed these practices did not follow professional standards for medication storage and labeling.
A facility failed to develop a comprehensive care plan for a resident with a baclofen pump. The resident's medical records lacked documentation of the pump, and staff were unaware of its presence until informed by the resident's wife. The care plan intervention for the pump was discontinued, leading to inadequate care planning for the resident's needs.
A resident with a baclofen pump was not properly monitored due to a lack of documentation and awareness among staff. The facility failed to ensure coordination of care, as the pump's presence and management were not included in the resident's medical record or care plan. Staff interviews revealed they were unaware of the pump until informed by the resident's family, leading to a deficiency in care.
The facility failed to maintain food service equipment and properly date and store food products, affecting 55 residents. Observations included loose temperature gauges on the dish machine, soiled flooring, and undated food items in refrigerators. These conditions indicate non-compliance with the 2017 FDA Model Food Code and the facility's sanitation policy.
The facility failed to maintain a clean and safe environment, affecting 55 residents. Observations included worn and damaged furniture, soiled surfaces, heavily stained carpeting, non-functional light assemblies, and missing tiles. Record reviews indicated that existing cleaning and maintenance policies were not effectively implemented.
The facility failed to ensure that two residents, who had not been deemed incapacitated, were acting as their own responsible party and to honor the code status wishes of one resident. One resident had conflicting documentation regarding their code status, and the facility could not provide documentation to support their incapacity. Another resident had their spouse designated as their responsible party without documentation to support their incapacity.
The facility failed to ensure accurate MDS coding for two residents. One resident's discharge was incorrectly coded as a hospital discharge instead of home, and another resident's MDS inaccurately reflected antidepressant use despite no prescription. The errors were confirmed by the MDS Coordinator.
Failure to Provide Timely Bathing and Hygiene Assistance for Dependent Post-Surgical Resident
Penalty
Summary
The facility failed to provide required assistance with activities of daily living (ADLs), specifically bathing and hygiene, for one dependent resident. The resident was admitted with diagnoses including malnutrition, postprocedural complications, and digestive system disorders, and had an abdominal surgical wound. An MDS assessment showed the resident had intact cognition with a Brief Interview for Mental Status score of 13/15. According to a family member interviewed by phone, the resident did not receive assistance with showers while in the facility and was often found soiled with urine and not cleaned up for the day. Review of the facility’s shower logs showed the resident did not receive a shower or bed bath until 11 days after admission, and review of progress notes revealed no documented refusals of bathing during that period. In an interview, the DON stated the facility’s expectation is that residents receive showers twice a week and that refusals are documented in the electronic medical record, but could not provide an explanation for the lack of showers for this post-surgical resident during the first 11 days after admission.
Failure to Provide Required Two-Person Assist During Transfer Resulting in Skin Tears
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, resulting in skin tears to both calves during a transfer back to bed. The resident had been admitted with diagnoses including malnutrition and postprocedural complications of the digestive system and had an abdominal surgical wound. An MDS assessment showed intact cognition. On the date of the incident, the resident reported feeling the backs of her legs pushing against the bedframe while being put back into bed and then feeling pinching, pain, and wetness under her legs, after which bleeding and skin tears were noted on the lateral aspects of both calves. The incident report identified that a mechanical lift (EZ stand) was in use during the transfer and that the resident experienced mild pain in her lower legs after being transferred to the bathroom and back. Interviews and record review revealed discrepancies and failures related to required transfer assistance. The DON reported that the resident required two-person assistance for transfers with an EZ stand and that a second staff member present in the room at the time of the incident was not assisting with the transfer but gathering supplies. The DON stated it was believed the resident’s loose skin was pinched between the bed frame and the EZ stand. In contrast, CNA F reported transferring the resident by herself, having the resident pivot from the wheelchair back to the bed, and stated that an EZ stand was not used and that she believed the resident was a one-person assist at the time. The resident’s care plan documented the resident as non-ambulatory with transfers requiring two-person assistance using a wheeled walker, and physician orders in effect at the time specified transfers with two-person assistance using an EZ stand.
Failure to Use Required PPE for Contact Precautions
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement its infection prevention and control program by not ensuring required PPE use for residents on Contact precautions. A resident admitted with diagnoses including malnutrition and Type 2 Diabetes Mellitus, and with moderately impaired cognition per a recent MDS, had physician orders for Contact transmission-based precautions for diarrhea. On multiple observations, CNAs entered and exited this resident’s room, which had a Contact precautions sign posted on the door, wearing only surgical masks and without donning gowns and gloves. One CNA acknowledged that Contact precautions required a gown and gloves and confirmed that neither she nor another CNA had donned the required PPE. The resident reported that staff did not wear gowns when entering the room and normally only wore gloves. A PPE cart near the resident’s room was observed to be missing gloves, and staff had to retrieve gloves from another resident’s room. Additional observations showed that a laundry aide entered four resident rooms without performing hand hygiene and wearing only a surgical mask, and then entered a room with a Contact precautions sign without donning any additional PPE. The laundry aide stated that she normally just went in and out with clean laundry without using a gown or gloves. The Corporate Infection Control staff member reported that the facility’s expectation was that all staff entering a Contact precautions room don a gown and gloves. The facility’s written Transmission-Based Precautions policy stated that healthcare personnel caring for residents on Contact precautions wear a gown and gloves for interactions that may involve contact with the resident or potentially contaminated areas in the resident’s environment, and that PPE is to be donned upon room entry and discarded before exiting to contain pathogens.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to implement its policies and procedures for timely reporting of a reasonable suspicion of a crime, as required by section 1150B of the Act. Two residents with cognitive impairments, one with Alzheimer's disease and severe impairment and another with unspecified dementia and moderate impairment, were involved in an incident where one resident was observed grabbing the other's foot. During care, the resident accused a staff member of attempted rape, prompting immediate cessation of care. Both residents were assessed and found to have no injuries. Law enforcement responded but could not obtain statements due to the residents' inability to recall the event. The incident occurred at 11:00 AM and was discovered at 12:30 PM, but was not reported to the State Agency until 5:02 PM, exceeding the required two-hour reporting window. The Nursing Home Administrator confirmed that abuse allegations must be reported immediately, but this protocol was not followed in this case.
Failure in Medication Management, Documentation, and Adherence to Physician Orders for Dialysis Residents
Penalty
Summary
The facility failed to ensure proper medication management, accurate documentation, recognition of changes in condition, and adherence to physician orders for two residents with end-stage renal disease dependent on dialysis. For one resident, there was an active physician order for transport to dialysis on specific days and notification of the physician for missed appointments, as well as weight monitoring. The resident's dialysis schedule was altered without justification or documentation, and there was no evidence of physician notification or weight documentation for missed or changed dialysis sessions. Additionally, the resident did not receive the prescribed Sevelamer HCl for chronic kidney disease, with multiple doses marked as administered on the MAR despite the medication not being available in-house. Nurses' notes indicated the medication was not available, and the DON confirmed the MAR entries were inaccurate and that the medication was never present during the resident's admission. The same resident experienced poor oral intake, with documentation showing less than 75% meal consumption at every meal and no evidence that snacks or alternatives were offered. There was only one recorded weight during the admission, reflecting a significant weight loss, with no documentation addressing the cause or interventions. The resident did not receive a Registered Dietician consultation or progress notes, and required social services assessments were not completed until after discharge. The social worker reported being unable to complete assessments due to the resident's lethargy but did not notify nursing staff, and there was no documentation of assessment attempts. Family members reported concerns about the resident's eating difficulties and mood changes, which were not addressed by the facility. For the second resident, there was also a failure to adhere to the prescribed dialysis schedule and to notify the physician or document weights when dialysis was missed or altered. The resident missed a dialysis session due to the facility not sending the required Hoyer sling, and there was no documentation of physician notification or weight monitoring. Dialysis communication forms were missing from the medical record, and staff could not explain the changes to the dialysis schedule. These deficiencies demonstrate a lack of compliance with physician orders, medication management, documentation, and recognition of changes in condition for residents requiring complex care.
Failure to Maintain Dialysis Coordination and Documentation
Penalty
Summary
The facility failed to maintain required dialysis coordination and communication documentation for two residents who required dialysis services. Both residents had physician orders specifying dialysis schedules and instructions to notify the physician of missed appointments and to obtain weights. However, the medical records for both residents lacked dialysis communication forms, documentation of physician notification, and records of weights when dialysis appointments were missed or altered. Staff were unable to explain or justify changes to the dialysis schedules, and there was no documentation to support why the residents' dialysis days were changed from the ordered schedule, despite the dialysis center being open on the originally scheduled days. One resident was not sent with the necessary Hoyer sling for transfer at the dialysis center, resulting in an incomplete dialysis session, and there was no documentation that the physician was notified or that a weight was obtained. The other resident's dialysis days were altered without explanation or documentation, and again, there was no evidence of physician notification or weight documentation. The Director of Nursing acknowledged that dialysis communication forms could not be located and that the facility was working to improve the process.
Failure to Accurately Document and Administer Ordered Medication
Penalty
Summary
The facility failed to ensure accurate documentation and proper maintenance of medical records for a resident admitted with end-stage renal disease dependent on dialysis and a disorder of phosphorus metabolism. The resident was prescribed Sevelamer HCl, an oral medication to manage hyperphosphatemia, to be administered three times daily with meals. Review of the Medication Administration Record (MAR) showed multiple instances where doses were marked as "OS" (see nurses' note) or as administered, but corresponding nurses' notes indicated the medication was not available. The MAR inaccurately reflected that some doses were given when, in fact, the medication was never present in the facility during the resident's stay. Interviews with the family member and the Director of Nursing (DON) confirmed that the resident did not receive any doses of Sevelamer from admission until discharge, as the medication could not be obtained from the pharmacy. The DON verified that the medication was not in the facility at any time and acknowledged that the MAR entries indicating administration were not accurate. The family was notified of the issue only after several days, and the resident was eventually transferred to a hospital due to a change in condition. The inaccurate documentation and failure to provide the ordered medication constituted a deficiency in maintaining accurate and complete medical records.
Unaddressed General Life Safety Code Requirements
Penalty
Summary
A deficiency was identified regarding general requirements under Life Safety Code (LSC) Sections 18.1 and 19.1 that were not addressed by the provided K-tags. The report notes that there are unmet general requirements, but does not specify the exact actions or omissions that led to the deficiency. No specific details about residents, staff, or events are provided in the report.
Failure to Assess and Monitor Respiratory Status Following Resident Distress
Penalty
Summary
The facility failed to adequately assess and monitor the respiratory status of a resident with a history of respiratory failure, COPD, obstructive sleep apnea, type 2 diabetes, and heart failure. Upon admission from the hospital, the resident arrived hypoxic, requiring high-flow oxygen and BiPAP, with persistent low oxygen saturation and increased work of breathing. Despite these critical symptoms, there was no documentation of a comprehensive respiratory assessment or clear orders for the use of CPAP or BiPAP in the medical record, and the admission assessment did not indicate the use of these devices. On the morning of the incident, the resident requested removal of their CPAP and assistance with oxygen via nasal cannula, reporting difficulty breathing. A CNA assisted with this request and reported the resident's oxygen saturation as 90-91%. However, there was no evidence that a licensed nurse performed a follow-up assessment after the resident reported respiratory distress. The resident was later found unresponsive, with signs of lividity and rigor mortis, and was pronounced deceased. The medical record also showed that as-needed inhaled medications for shortness of breath were not administered or documented as given. Interviews with staff revealed uncertainty regarding the oxygen flow rate and a lack of clarity about the resident's respiratory status prior to being found unresponsive. The facility's Regional Clinical Director acknowledged that a follow-up nursing assessment should have occurred after the resident reported difficulty breathing. The failure to assess and monitor the resident's respiratory status after a report of distress directly contributed to the deficiency.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The facility failed to ensure timely response to call lights for five residents, as evidenced by direct observations, resident interviews, and review of call light response time reports. Residents with moderate cognitive impairment, diabetes, heart failure, peripheral vascular disease, and end stage renal disease reported waiting between 15 minutes to as long as two hours for staff assistance after activating their call lights. These delays occurred across multiple shifts, with some residents specifically noting longer wait times during shift changes. Call light response reports confirmed that call lights remained on for over 20 minutes on numerous occasions, with the longest single wait times ranging from 33 to 39 minutes for individual residents. Residents described waiting extended periods for assistance with toileting, transfers, and other personal care needs, sometimes resulting in episodes of incontinence. The facility's own records corroborated these reports, showing repeated instances where call lights were not answered within the facility's stated goal of 10 minutes. The Nursing Home Administrator acknowledged awareness of the issue and ongoing complaints regarding delayed response times.
Failure to Provide Timely and Accurate Medicare Coverage Notices
Penalty
Summary
The facility failed to provide timely and accurate Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents. For one resident, the NOMNC indicated the last covered day under Medicare A would be 4/16/25, but the notice was signed only one day prior, on 4/15/25, not meeting the required advance notice period. The corresponding SNF ABN was also signed on 4/15/25, stating that private billing would begin on 4/18/25. For another resident, the NOMNC showed the last covered day as 2/19/25, but the form was signed and dated on the same day, again failing to provide the required notice period. During an interview, the social worker responsible for issuing these notices confirmed her responsibility and usual practice of providing three days' notice, but could not explain why the notices for these two residents were issued late and inaccurately.
Failure to Develop and Implement Comprehensive Activity Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing the activity preferences and needs of a resident with multiple complex medical diagnoses, including neurocognitive disorder, depression, and chronic pain. The resident, who had moderate cognitive impairment, reported feeling bored and was unaware of any activity calendar or invitations to participate in facility activities. Observations confirmed that no activity calendar was posted in the resident's room during initial visits, and the medical record lacked documentation of a care plan for activity preferences, despite the Life Enrichment Assessment indicating that functional status related to activities should be addressed in the care plan. Interviews with facility staff, including the Nursing Home Administrator and Activity Assistant, revealed that it was expected for all residents to have documented activity preferences in their care plans and to receive an activity calendar. However, the resident's records did not reflect these practices, and activity participation documentation showed mostly solitary activities, with limited staff involvement and no evidence of group activities being offered. The deficiency was identified through observation, interview, and record review, highlighting the facility's failure to ensure a comprehensive, individualized care plan for the resident's activity needs.
Failure to Provide Individualized Activities and Activity Planning
Penalty
Summary
The facility failed to provide meaningful, individualized activities for one resident with multiple complex medical conditions, including Lewy Body Dementia, depression, and schizoaffective disorder. The resident was observed multiple times sitting alone in her room and expressed feeling bored. She reported not being aware of any activity calendar or being invited to participate in facility activities. No activity calendar was observed in her room during initial observations, and her medical record did not include a care plan outlining her activity preferences or interests. The Life Enrichment Assessment indicated a need to address functional status in the care plan, but this was not reflected in her records. Documentation of the resident's activity participation over the past 30 days showed only solitary activities, such as conversation/reminiscing, with several instances occurring without staff involvement. There was no evidence of group activities being offered. Interviews with facility staff confirmed that it was expected for all residents to receive an activity calendar and have their activity preferences included in their care plan, but this was not done for this resident. The deficiency was identified through observations, interviews, and record reviews, which demonstrated a lack of individualized activity programming and failure to follow facility expectations for activity provision and documentation.
Failure to Ensure Proper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for two residents. One resident was observed with a Trelegy inhaler and Azelastine nasal solution at her bedside and reported self-administering these medications without nurse supervision. There was no physician order, self-administration assessment, or care plan in place for this resident to self-administer medication. Another resident was found with a dulera inhaler and fluticasone nasal spray on her bedside table, which had been left by a nurse without being administered. This resident stated she does not self-administer medication, and there was no assessment, physician order, or care plan for self-administration in her record. Additionally, during a review of the medication storage room, an opened multi-dose vial of tuberculin was found in the refrigerator without a date indicating when it was opened. Staff interviews confirmed that it is professional practice to date multi-dose vials upon opening, and the LPN acknowledged the vial should have been dated and would be disposed of. These findings demonstrate failures in medication storage, labeling, and adherence to professional standards for medication management.
Failure to Implement Comprehensive Care Plan for Resident with Baclofen Pump
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who had a baclofen pump. The resident was admitted with diagnoses including dementia and a baclofen pump, which was not properly documented in the care plan. The medical records from the physician's office managing the baclofen pump indicated a scheduled decrease in dosage and a plan for oral baclofen administration, but this information was not included in the resident's medical record at the facility. Consequently, there were no orders or care plans indicating the presence of the baclofen pump until shortly before the resident's death. Interviews with facility staff, including LPNs, the Clinical Care Coordinator, and the Director of Nursing, revealed a lack of awareness about the resident's baclofen pump until it was mentioned by the resident's wife. The staff reported that if a resident had a baclofen pump, it should have been included in the care plan. The facility's documentation showed that the baclofen pump was last filled on a specific date, but the care plan intervention for the pump was discontinued, leading staff to believe it was no longer in use. This oversight resulted in a failure to provide appropriate care planning for the resident's medical needs.
Failure to Monitor Baclofen Pump in Resident
Penalty
Summary
The facility failed to ensure proper coordination of care and monitoring for a resident with a baclofen pump, an implanted device that delivers muscle relaxant medication directly into the spinal fluid. The resident, who had diagnoses including dementia and muscle contracture, was admitted with a baclofen pump that was not adequately documented or monitored. The family reported that the pump was due to run out of medication, but the facility had no records or care plans indicating the presence of the pump or the need for monitoring for baclofen withdrawal. Interviews with staff revealed a lack of awareness about the resident's baclofen pump. Several Licensed Practical Nurses (LPNs), the Clinical Care Coordinator (CCC), and the Director of Nursing (DON) were unaware of the pump until informed by the resident's family. The facility's documentation showed that the baclofen pump was last filled several months prior, and there was no subsequent documentation or care planning for the pump's management or the resident's potential withdrawal symptoms. The facility's failure to document and monitor the baclofen pump led to a lack of appropriate care for the resident. The resident's medical record did not include necessary orders or care plans for the baclofen pump, and there was no monitoring for withdrawal symptoms after the pump was empty. This oversight resulted in a deficiency in the coordination of care for the resident, as the staff was not informed or prepared to manage the resident's condition effectively.
Deficiencies in Food Service Equipment Maintenance and Food Storage
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, date mark all potentially hazardous ready-to-eat food products, and properly date, label, and store food products, affecting 55 residents. During a comprehensive tour of the food service area, several deficiencies were noted, including loose and fogged temperature gauges on the mechanical dish machine, soiled flooring surfaces in the Dietary Manager's office and walk-in cooler, and an improperly mounted garbage disposal spray arm valve assembly. Additionally, the can opener mounting bracket and the door gaskets of the True 2-door reach-in cooler were observed with accumulated food residue and dirt deposits. Further observations revealed that the reach-in refrigerator contained uncovered frozen vegetables, expired grapes, and an opened half-gallon of whole milk without a date. The walk-in refrigerator also contained an undated container of pasta salad. These findings indicate a failure to adhere to the 2017 FDA Model Food Code, which requires proper maintenance of equipment, cleanliness of food-contact surfaces, and appropriate date marking of potentially hazardous ready-to-eat food products. The facility's policy on sanitation inspection, dated 08-11-2022, was reviewed and found to be in non-compliance with state and federal regulations. The policy mandates that all food service areas be kept clean, sanitary, and free from litter and rubbish. However, the observed conditions, including soiled equipment and improper food storage practices, demonstrate a significant lapse in maintaining the required standards of cleanliness and food safety, thereby increasing the potential for cross-contamination and foodborne illnesses among residents.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, affecting 55 residents. During an environmental tour, several deficiencies were noted, including worn and damaged furniture, soiled and encrusted surfaces, and heavily stained and soiled carpeting. Specific areas of concern included the nurses' stations, beauty shop, rehabilitation unit, memory care unit, dining rooms, janitor closets, and activity rooms. Additionally, non-functional light assemblies and missing tiles were observed, indicating a lack of proper maintenance and cleaning routines. Record reviews revealed that the facility had policies in place for routine cleaning and disinfection, as well as environmental services inspections. However, the observations made during the tour indicated that these policies were not being effectively implemented. The deficiencies noted increased the likelihood of cross-contamination, bacterial harborage, and decreased air quality, posing a risk to the health and safety of the residents, staff, and the public.
Failure to Honor Resident's Code Status and Decision-Making Rights
Penalty
Summary
The facility failed to ensure that two residents, who had not been deemed incapacitated, were acting as their own responsible party and to honor the code status wishes of one resident. Resident #37, who was cognitively intact with a BIMS score of 13 out of 15, had conflicting documentation in their medical record regarding their code status. Despite having a DNR document signed by the resident, the Director of Nursing (DON) reported that the resident was not their own responsible party and that the DNR was invalid. However, there was no documentation provided to support that Resident #37 had been deemed incompetent to make their own medical decisions. Additionally, the resident's OBRA Level II Evaluation indicated that they acted as their own person for medical and daily choices, although they had a conservator for financial decisions due to a traumatic brain injury. The facility failed to provide documentation to the survey team that supported the resident's incapacity to make medical decisions before the survey exit date. Furthermore, the DON reported that the resident had expressed a desire to be a full code status upon returning from the hospital, contradicting the previously signed DNR document. This inconsistency in honoring the resident's code status wishes was a significant deficiency in the facility's care practices. Resident #3, who had severe cognitive impairment with a BIMS score of 5 out of 15, had their spouse designated as their responsible party. However, there was no documentation to support that Resident #3 had been deemed incompetent to make their own medical decisions. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) both reported that the resident's spouse was making medical decisions on their behalf, but they were unable to provide any capacity determination documentation. This lack of documentation to support the resident's incapacity to make their own medical decisions was another significant deficiency in the facility's care practices.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) Assessments for two residents. Resident #54 was admitted to the facility and later discharged home, but the Discharge MDS incorrectly indicated that the resident was discharged to the hospital. This error was confirmed by the MDS Coordinator during an interview. Resident #37, who had diagnoses including diabetes, depression, and schizophrenia, was found to have an error in the quarterly MDS. The MDS incorrectly reflected the use of an antidepressant, although the resident had not been prescribed any antidepressant since admission. The MDS Coordinator acknowledged the coding error, attributing it to a possible misclassification of an antipsychotic medication as an antidepressant.
Latest citations in Michigan
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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