Christian Park Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Escanaba, Michigan.
- Location
- 2415 5th Avenue South, Escanaba, Michigan 49829
- CMS Provider Number
- 235244
- Inspections on file
- 28
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Christian Park Health Care Center during CMS and state inspections, most recent first.
A cognitively intact resident with chronic hypoxic respiratory failure and morbid obesity was transferred to a hospital with unclear and poorly documented reasons in the EMR, which only noted constipation and an O2 saturation in the low 80s. The ADON acknowledged that the discharge was not properly documented and that the reason for sending the resident out was unclear. After the resident became medically stable in an out-of-state hospital, the resident, hospital CM, and Ombudsman reported that the resident wished to return and had been educated on the risks of using BiPAP instead of AVAP, but the NHA repeatedly delayed or refused readmission, citing an inability to manage AVAP and daily ABGs despite a sister facility’s experience with AVAP. A hospital-arranged transport returned the resident to the facility after a long trip, but staff, reportedly under the NHA’s direction, did not open the door or accept the resident, forcing a return trip to the hospital. These actions conflicted with the facility’s own transfer/discharge policy requiring clear physician documentation, appropriate criteria for transfer, and proper notice and process.
A resident with chronic respiratory failure and intact cognition was transferred twice to hospitals, including an out-of-state facility for acute on chronic hypoxic respiratory failure, acute hypercapnic respiratory failure, and sepsis. Review of the EMR and interviews with the ADON showed there was no written transfer notice, no documentation that bed-hold and readmission policies were provided, and no required hospital transfer paperwork, despite facility policy requiring these actions for emergency transfers. This lack of required documentation and notification caused the resident worry, fear, and frustration and contributed to a delay in readmission after a prolonged hospitalization.
A resident with dementia and a history of constipation experienced prolonged periods without bowel movements, despite having scheduled and PRN medications available. Staff failed to administer PRN interventions or document timely assessments, leading to worsening abdominal pain, vomiting, and eventual hospitalization for small bowel obstruction, acute kidney injury, and sepsis. Facility staff later acknowledged documentation and communication failures regarding bowel management.
A resident with dementia and cognitive impairment, identified as being at risk for constipation, experienced prolonged periods without bowel movements despite having PRN medications available. The care plan was not updated or followed, and interventions were not implemented, resulting in the resident developing a small bowel obstruction, acute kidney injury, and sepsis, requiring hospitalization.
A resident with paraplegia and a history of depression was restricted from using his electric wheelchair inside the facility after a single incident, while other residents were not similarly restricted. The resident's requests, such as excluding the DON from his care conference, were disregarded by management, leading to increased anxiety and feelings of being targeted. Staff and the ombudsman confirmed the resident felt disrespected and that his rights to dignity and self-determination were not honored.
The facility failed to provide prescribed therapeutic diets to three residents, leading to potential health risks. One resident received a dinner roll against dietary instructions, another was served non-ground turkey despite needing ground meats, and a third received a salt packet despite a no-added-salt diet due to hypertension. Staff acknowledged these errors during observations.
Failure to Properly Document Transfer and Timely Readmit a Cognitively Intact Resident After Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to timely and appropriately readmit a cognitively intact resident after a hospital transfer, and failure to properly document and manage the original transfer/discharge. The resident had chronic hypoxic respiratory failure, morbid obesity (over 500 pounds), used 4 L O2 during the day, and BiPAP at night and for naps. The resident’s MDS and behavioral health documentation showed a BIMS score of 14/15, indicating intact cognition. The facility’s EMR documented that the resident was sent to the ED for “no BM for 3 days,” with a change in condition note showing an O2 saturation of 84% on oxygen via nasal cannula and a recommendation to send to the ER. The ADON stated that the EMR did not clearly or properly document the reason for the transfer, that the facility’s practice was not to send residents out solely for constipation, and that alternative measures should have been used. The ADON also reported being unsure why the resident was sent out and acknowledged that the discharge was not properly documented. The NHA reported that the resident was initially transferred to the local ED for a hypoxic episode and then to an out-of-state hospital, and later stated that the resident would not be readmitted until “stable,” citing a need for an AVAP machine and daily ABGs that the facility allegedly could not manage. However, the resident’s EMR from prior months showed baseline O2 saturations in the mid‑80s, with some readings as low as 69% and 71%, and the out-of-state hospital record described chronic hypoxic respiratory failure on 2 L O2 at baseline. The hospital admission record from the out-of-state facility stated that the resident presented from the nursing facility with acute worsening dyspnea and hypoxia, with O2 saturation dropping to 55% on BiPAP at the facility, but there was no corresponding documentation in the facility’s EMR of such a drop. The NHA acknowledged being unaware that the last EMR note before transfer only referenced no bowel movement for three days and confirmed that whatever was in the EMR was all the facility had regarding the discharge. After the resident became medically stable at the out-of-state hospital, the resident, the hospital CM, and the Ombudsman all reported that the resident wished to return to the facility and had been educated extensively on the risks of using BiPAP instead of AVAP. The Ombudsman and the hospital CM stated that the NHA repeatedly delayed readmission, asserting the facility could not care for someone on AVAP, despite the Ombudsman and a DON at a sister facility confirming that the sister facility had experience with AVAP and a resident using it. The Ombudsman and CM described an incident in which the hospital discharged the resident back to the facility, arranging a nearly five-hour transport; upon arrival, facility staff, reportedly under the NHA’s direction, did not open the door or accept the resident, and the driver had to return the resident to the out-of-state hospital after another long trip. The resident reported feeling fine on the day of the original transfer, not understanding why he was sent out, and later described the return trip and refusal at the door as feeling like being treated as “garbage” in a “meat wagon.” The facility’s own transfer and discharge policy required that transfers/discharges be necessary for the resident’s welfare, properly documented by a physician, and accompanied by written notice and appeal rights, but the record review and interviews showed unclear documentation of the reason for transfer, lack of proper discharge documentation, and delayed or refused readmission despite the resident’s expressed desire and documented capacity to return. The NHA also reported that the Ombudsman had filed an appeal with the State Agency alleging an involuntary discharge and that the State Agency requested an involuntary discharge form, but the NHA had not yet provided anything back. The hospital CM stated that the resident had been medically stable for several days, no longer required daily ABGs, and that the resident understood and accepted the risks of his choices. The CM further reported repeated denials of readmission, difficulties in communicating with the facility, and that progress notes and discharge summaries had been sent to the NHA, who at times claimed not to have received them. During the survey, the NHA initially provided only 9 of 54 pages of the hospital discharge summary, attributing this to the admissions coordinator’s printer running out of paper, and there were multiple delays in providing requested documents. Collectively, these actions and omissions resulted in the resident not being timely readmitted to his home facility, despite his wishes, his cognitive capacity, and the hospital’s assessment of medical stability, and were inconsistent with the facility’s own transfer and discharge policy requirements.
Failure to Provide Required Transfer Notices and Bed-Hold Information During Hospitalizations
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its transfer and discharge policy by not providing required written transfer notifications, bed-hold policy information, and hospital transfer documentation for a cognitively intact resident. The resident was originally admitted with diagnoses including respiratory failure and had a BIMS score of 14/15, indicating intact cognition. The resident’s EMR showed that he was sent to a local emergency department for no bowel movement for three days and had previously been transferred to an out-of-state hospital after the facility noted his oxygen saturation was 65% on his baseline 2 L oxygen, leading to admission for acute on chronic hypoxic respiratory failure, acute hypercapnic respiratory failure, and sepsis secondary to bilateral pneumonia, UTI, bacteremia, and cellulitis. During review, the ADON identified that the EMR reflected discharges from the facility and admissions to the hospital on two separate occasions. Despite these transfers, the EMR contained no evidence of a written notification of transfer to the resident or resident representative and no documentation that the facility’s bed-hold and readmission policies were provided, as required by the facility’s own policy. The facility’s policy specified that, for emergency transfers, notice of transfer must be provided to the resident and representative as soon as practicable, a physician’s order with date and reason for transfer must be obtained, written notice of bed-hold and readmission policies must be given at the time of transfer or within 24 hours, and a transfer form, medication list, and care plan goals must be sent to the receiving hospital, with nursing documenting the hospital transfer in the medical record. At the time of the survey exit, there was no required documentation in the resident’s EMR, including the bed-hold notice, written transfer notice, or hospital transfer paperwork, and this failure resulted in worry, fear, and frustration for the resident and delayed his readmission from a lengthy out-of-state hospitalization.
Failure to Prevent and Treat Constipation Resulting in Harm
Penalty
Summary
The facility failed to implement preventative measures, promptly assess, and treat constipation for a resident with dementia, resulting in actual harm. The resident had a documented history of constipation and was prescribed both scheduled and PRN medications for bowel management. Despite this, documentation showed prolonged periods without bowel movements, including a six-day and a ten-day interval with minimal or no bowel movements. During these periods, there was no evidence that PRN medications for constipation were administered, even though they were available and ordered. Nursing and CNA documentation indicated that the resident experienced increasing abdominal pain, decreased appetite, and eventually vomiting. Nursing staff noted the absence of regular bowel movements and administered a rectal suppository only after the resident began to show significant symptoms. The resident's condition deteriorated further, with continued abdominal pain, lethargy, fever, and abnormal vital signs. The on-call physician's assistant was contacted, and an abdominal X-ray was ordered, but the resident's status continued to decline, leading to transfer to the hospital. At the hospital, the resident was diagnosed with a small bowel obstruction, acute kidney injury, and sepsis. The hospital course included non-operative management due to the resident's advanced age and comorbidities, and the plan was shifted to comfort-focused care. The facility's own staff and leadership acknowledged issues with documentation and communication regarding bowel management, and the lack of timely intervention and follow-through on bowel protocols contributed to the resident's decline and subsequent hospitalization.
Failure to Revise and Implement Care Plan for Constipation Management
Penalty
Summary
The facility failed to implement, review, and revise the care plan and interventions for a resident at risk for constipation, resulting in a delay in treatment and subsequent medical complications. The resident, who had dementia and was cognitively impaired, was identified as being at risk for constipation due to decreased mobility, medication side effects, and opioid use. The care plan included interventions such as monitoring for signs and symptoms of constipation, administering medications as ordered, and reporting abnormal findings to the physician. However, documentation revealed that the resident went extended periods without bowel movements, specifically six days without a bowel movement and another ten-day period with only one medium bowel movement. Despite having PRN medications available for constipation relief, including stool softeners, laxatives, suppositories, and enemas, there was no documentation that any of these were administered during the periods of constipation. Progress notes indicated that the resident later experienced a large episode of dark brown emesis and was subsequently sent to the hospital for evaluation of fever and hypotension. Hospital records confirmed the development of a small bowel obstruction, acute kidney injury, and sepsis. Interviews and record reviews confirmed that the care plan was not followed or updated to reflect the resident's changing condition. The Director of Nursing acknowledged that the care plan should have been person-centered and interventions implemented to meet the resident's goals. Reference materials cited in the report emphasized the importance of revising care plans based on the resident's current status and needs, which was not done in this case.
Failure to Honor Resident Dignity and Rights
Penalty
Summary
A resident with paraplegia and a history of major depressive disorder was admitted to the facility and was cognitively intact, as evidenced by a BIMS score of 15/15. The resident had previously been involved in an incident where he accidentally bumped into another resident with his electric wheelchair, resulting in no injury but some pain. Following this incident, the facility restricted his use of the electric wheelchair within the building, allowing him to use it only when leaving the facility. The resident expressed that other residents were not similarly restricted after incidents, and he felt targeted and unfairly treated. Staff interviews confirmed that the resident had not been given a second chance to use his electric wheelchair inside the facility, and no education or interventions were provided to address the incident or prevent recurrence. The resident repeatedly voiced feelings of anxiety, frustration, and fear of retaliation or discharge due to the way management handled his situation. He reported that his requests, such as not having the DON present at his care conference, were disregarded by the former NHA, who insisted on the DON's attendance despite the resident's objections. Multiple staff members and the facility ombudsman corroborated that the resident felt disrespected, bullied, and that his rights were not honored. The resident also experienced additional distress when required to use a large orange flag on his wheelchair against his wishes and when his television access was disrupted without timely resolution from management. Documentation and interviews revealed that the facility failed to maintain the resident's dignity and respect his rights to self-determination and participation in care planning. Staff did not document or communicate the resident's grievances or emotional distress to management or the social worker, and interventions to establish a trusting relationship and maintain a non-threatening environment were not effectively implemented. The facility's own policies on resident dignity and rights were not followed, as the resident's preferences and autonomy were repeatedly overridden by management decisions.
Failure to Provide Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to ensure that residents received food as prescribed by a physician and in accordance with their preferences, affecting three residents. For one resident, a lunch tray included a dinner roll despite instructions indicating no bread unless it was a sandwich. The resident did not consume the roll, which was returned untouched. The Certified Dietary Manager acknowledged that bread should not have been on the tray with manicotti, as per the resident's request. Another resident was observed attempting to cut a turkey slice with a fork, although their therapeutic diet required ground meats. The resident indicated a preference for ground turkey, and a Certified Nurse Aide recognized the error and sought to correct it by obtaining ground turkey from the dietary department. Additionally, a third resident received a breakfast tray with a salt packet, contrary to their prescribed diet of no added salt due to hypertension. A Registered Nurse confirmed the presence of salt was inappropriate for the resident's condition.
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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