Clearstream Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hastings, Michigan.
- Location
- 240 E North St, Hastings, Michigan 49058
- CMS Provider Number
- 235281
- Inspections on file
- 19
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Clearstream Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Two residents with dementia and mental health conditions became involved in a physical altercation after one resident, who frequently wandered and picked up items, took a pair of gloves belonging to another resident. The second resident, who had a history of depression, suicidal ideation, and irritability, followed and forcefully grabbed the first resident’s arm, prompting the first resident to slap her in the face. Care plans did not address the first resident’s behavior of picking up others’ belongings or the second resident’s frustration with peers, despite known patterns of wandering, item-handling, and conflict with other residents. A family member witnessed the incident, and staff interviews confirmed the behavioral patterns that led to the conflict, which met the facility’s own policy definitions of physical abuse (hitting, slapping, grabbing).
A nurse administered a discontinued dose of Meloxicam to a resident after failing to reconcile the medication with the current physician order and not removing the outdated medication card from the cart. Multiple medication cards for both discontinued and current dosages were present, and audits of medication administration and storage did not consistently check for discontinued medications, leading to a medication error.
Surveyors found that medication carts were not properly managed, including missing narcotic count documentation, discontinued medications left accessible and administered to a resident, and an insulin pen in use without an open date. LPNs and other staff acknowledged lapses in following procedures for medication removal and labeling, and audits did not consistently check for discontinued medications.
The facility failed to maintain a sanitary environment in Resident #61's room and the spa room, with issues such as debris and stains. Additionally, the locked memory care unit's dining room did not provide a home-like atmosphere, as meals were served on trays, unlike the main dining room. Staff interviews revealed a lack of understanding regarding the differing meal service practices.
The facility failed to notify the provider of missed medication doses for two residents, one with atrial fibrillation and another with hypertension and a PEG tube. Medications were not reordered in time, leading to missed doses, and feeding tube orders were not in place, resulting in missed flushes. Staff interviews revealed systemic issues with medication reordering and communication.
The facility failed to provide adequate grooming for four residents with severe cognitive impairments, resulting in unkempt appearances and potential embarrassment. Observations showed these residents had noticeable facial hair that was not addressed, despite the facility's policy to improve appearance according to preferences. Staff interviews revealed a lack of awareness of residents' grooming preferences, and no documentation was provided to justify the lack of care.
The facility failed to provide residents with their food and beverage preferences, leading to incorrect items being served. Observations showed residents receiving beverages and nutritional supplements that did not match their meal tickets, such as being served Ensure Plus instead of Boost. Additionally, meals did not align with dietary needs or preferences, like serving regular jam to a diabetic resident. Staff interviews revealed these discrepancies were due to the dietary department providing available items rather than preferred ones.
A resident reported overhearing CNAs making derogatory comments about another resident's hygiene, which was not thoroughly investigated by the facility. Despite being cognitively intact, the resident's concerns were not adequately addressed by the Unit Manager or other staff, leading to a lack of communication and follow-up. The Director of Nursing was unaware of the incident, and grievance forms were not provided, indicating a failure in documentation and response to resident complaints.
A facility failed to update a resident's advanced directive and code status, despite requests from the designated patient advocate. The resident, unable to make medical decisions, was listed as Full Code, contrary to their signed directive and the advocate's request for DNR status. The advocate, living out of state, struggled with decision-making responsibilities and requested guardianship, which the facility did not initiate.
A facility failed to notify a resident's emergency contact of a change in condition, involving bruising and a laceration discovered during catheterization. The resident, who was moderately cognitively impaired with dementia and Alzheimer's, had their condition noted by a nurse, but the family was not informed, as confirmed by the DON.
A facility failed to prevent the misappropriation of a resident's narcotic medications, resulting in the loss of pain medication. An RN signed for a new Norco prescription but did not add it to the narcotic count sheet, leading to a discrepancy. The RN tested positive for opioids and oxycodone, and the facility concluded that the RN diverted the Percocet, as she could not provide a valid prescription for oxycodone and failed to follow proper procedures.
A facility failed to follow its abuse policy when staff did not report observations of potential sexual abuse of a resident with dementia and Alzheimer's disease. Despite noticing bruising and swelling in the resident's genital area, staff did not immediately inform the Nursing Home Administrator as required. The Administrator only learned of the injury weeks later, highlighting a lapse in the facility's reporting procedures.
A resident with dementia and muscle weakness experienced multiple falls due to the facility's failure to update the care plan with appropriate fall prevention interventions. Despite being at high risk for falls, the resident's care plan did not include the use of a fall mat, which was not consistently placed by the bed. Staff interviews confirmed the lack of documentation and communication regarding this intervention.
A resident with multiple pressure ulcers did not receive necessary care to prevent and treat her condition. Despite having a care plan that included the use of bilateral boots for offloading, these were not consistently applied. Observations showed the resident often without the prescribed boots, and staff interviews revealed a lack of adherence to the care plan. The MAR/TAR inaccurately indicated the boots were applied, contributing to the deficiency in pressure ulcer care.
A resident with multiple health conditions and a high fall risk experienced two falls due to staff failing to use prescribed assistive devices during transfers. Despite training, a CNA did not use a slide board or gait belt, leading to the resident being found on the floor on separate occasions.
A facility failed to provide timely emergency physician services for a resident with multiple health conditions who had not voided for 13 hours after returning from the hospital. Despite multiple attempts to contact the resident's physician and the facility's on-call provider, no immediate medical intervention was provided, leading to significant urinary retention. The facility lacked a contingency plan for emergency care when the resident's independent physician did not respond.
Two residents experienced medication administration errors, leading to a 12% error rate. A resident received an incorrect dose of Depakote due to an incomplete order, and another resident missed a dose of Symbicort inhaler because it was not available. The LPN failed to follow the facility's medication administration policy, which requires verifying orders before administration.
The facility failed to properly label, date, and store medications in the medication cart. An opened insulin lispro pen was found without an open date, and in the stock meds area, an opened bottle of Mucus ER and Cetirizine 10 mg were also missing open dates. RN FF confirmed that nurses were supposed to label medications with open dates, but this was missed. The DON reported that night shift staff were expected to review medication carts to ensure proper labeling.
The facility failed to implement Enhanced Barrier Precautions for two residents, one with a urinary catheter and another with a feeding tube. Observations showed a lack of signage and PPE, and staff did not consistently use gloves and gowns during care activities, despite the requirements. This resulted in potential cross-contamination risks.
The facility failed to prevent elopement for two residents and ensure safe mechanical lift transfers for another, resulting in Immediate Jeopardy. One resident expressed a desire to leave and was not reassessed for elopement risk, while another with a known history of elopement was found outside. Additionally, a resident was injured during a lift transfer due to improper equipment maintenance and staff training.
The facility failed to protect residents from abuse, resulting in incidents where a resident physically assaulted another, and another resident engaged in inappropriate sexual behavior. Despite care plans, interventions were insufficient, leading to emotional distress and physical harm. The facility's policy on abuse was not adequately enforced, contributing to these deficiencies.
A resident with dementia and other health issues fell from a mechanical lift and sustained a head injury. A CNA moved the resident back to bed without waiting for a nurse's assessment, contrary to facility policy and guidelines. The resident was later hospitalized and returned with stitches and a hematoma. Staff interviews confirmed the breach in protocol.
A resident with severe cognitive impairment and limited mobility was injured during a transfer when a CNA failed to use the prescribed sit-to-stand lift, resulting in a laceration requiring sutures. The CNA did not check the care plan and manually transferred the resident, leading to the injury.
A resident with dementia experienced two unwitnessed falls resulting in head trauma, but the facility failed to notify the physician. The resident was on hospice care, and facility staff assumed the hospice nurse would inform the hospice physician. However, the hospice nurse expected the facility to notify the resident's physician directly. A follow-up visit note lacked any mention of the falls, highlighting a communication breakdown.
A facility failed to prevent physical abuse between two residents with dementia, resulting in repeated incidents of aggression. Despite known triggers and a history of aggression, the facility lacked consistent supervision and effective interventions, leading to physical altercations. Staff interviews highlighted insufficient dementia training and inadequate supervision, particularly during weekends and evenings.
A resident with dementia experienced a right hip fracture that was not reported as an injury of unknown origin by the facility. The fracture was discovered after the resident complained of pain, but the facility attributed it to a previous fall without proper documentation or timely reporting. Interviews and records indicated a lack of immediate pain or injury signs post-fall, leading to a delay in investigation.
A resident with dementia experienced two falls in one night, but the facility failed to document a complete post-fall assessment. Although the resident initially showed no abnormalities, a hip fracture was discovered two days later when the resident complained of leg pain. The lack of documentation delayed necessary interventions.
Failure to Prevent Resident-to-Resident Physical Altercation Over Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident-to-resident physical abuse when two residents engaged in a physical altercation. One resident with Alzheimer’s disease and generalized anxiety disorder, who was severely cognitively impaired with a BIMS score of 0/15, frequently walked around the unit and picked up items in her environment. Her care plan identified that she spent time walking around the unit picking up sensory items and directed staff to offer cues and prompts as needed, but there was no care plan addressing her behavior of picking up other residents’ belongings. On the day of the incident, this resident walked by another resident in the dining area and picked up a pair of gloves that were next to the second resident, then walked away carrying the gloves. The second resident involved had unspecified dementia, major depressive disorder, and a history of suicidal ideation, with a BIMS score of 12/15 indicating moderate cognitive impairment. Her care plan identified risk for psychosocial well-being concerns related to suicidal ideation and included an intervention to remove residents to a calm, safe environment when conflict arises, but there was no care plan addressing her frustration with peers. A family member witness reported that after the first resident picked up the gloves and began walking down the hall, the second resident followed, forcefully grabbed the first resident’s arm, and pulled back in a way that caused the first resident to turn around. In response, the first resident slapped the second resident on the side of the face, after which the second resident appeared angered and verbally stated that she had been slapped. Staff interviews and documentation further described the residents’ behaviors and the circumstances leading to the altercation. An LPN stated that the first resident frequently explored her environment by picking up items and did not have the capacity to consider ownership of the items she handled. A CNA reported that the second resident felt frustrated by the actions of other residents and would respond by yelling at them. A progress note documented that the second resident had been upset about a disagreement with another resident over her gloves, and a later psychiatric evaluation noted that she argued with another resident and had current symptoms including anxiety, depression, and irritability. The facility’s Resident Rights, Abuse and Neglect policy defined physical abuse to include hitting, slapping, and grabbing, and the reasonable person concept was applied to determine that neither resident would want to be grabbed forcefully by the arm or slapped in the face, establishing that the resident-to-resident physical contact constituted abuse that the facility failed to prevent.
Medication Administration Error Due to Failure to Remove Discontinued Medication
Penalty
Summary
A deficiency occurred when a nurse failed to follow professional standards of nursing practice during medication preparation and administration for a resident. The nurse retrieved and administered Meloxicam 7.5 mg from a medication card that had been discontinued, instead of the current order for Meloxicam 15 mg once daily. The discontinued medication card was not removed from the medication cart after the physician changed the order, leading to the administration of the incorrect dose. The nurse did not reconcile the medication dosage against the physician order prior to administration. Interviews with facility staff revealed that there were multiple medication cards for both the discontinued and current dosages in the cart, and that audits of medication administration and cart storage were performed without consistently checking for discontinued medications. Documentation of medication pass audits was incomplete, lacking details such as dates, resident names, or specific medications observed. Professional standards, including the six rights of medication administration, were not consistently followed, resulting in a medication error for the resident.
Medication Labeling, Storage, and Administration Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices. On one medication cart, the narcotic count sheets were not verified for the current day, with the last entry recorded the previous night. The Assistant Director of Nursing (ADON) confirmed that narcotic counts should be performed and documented at each shift change, but the responsible LPN had not completed the count and cited the absence of a log sheet as a possible reason. Additionally, another LPN admitted to not having counted narcotics that day. Further observations revealed that a resident was administered Meloxicam 7.5 mg, which had been discontinued per physician orders and replaced with a 15 mg dose. The discontinued medication remained in the cart alongside the new medication, and the LPN acknowledged the error after reviewing the orders. Another issue was found with an insulin pen in a medication cart that was in use but lacked an open date, which the LPN attributed to forgetting to date it. Audits performed by the ADON and Unit Manager (UM) focused on medication administration and storage, but the UM reported not regularly checking for discontinued medication cards, and insulin pens were not always dated upon opening.
Deficiencies in Sanitation and Dining Environment
Penalty
Summary
The facility failed to maintain a sanitary and orderly environment in two specific areas: Resident #61's room and the spa room between C and D hall. Observations revealed that Resident #61's room had a windowsill track littered with dead bugs, dust, and debris, a cracked and chipped tile sill, and a headboard with veneer pulled away, leaving a large gap. Additionally, a window curtain had a noticeable stain. Resident #61, who was cognitively intact, expressed dissatisfaction with the room's condition, comparing it unfavorably to her home environment. In the spa room, a padded shower chair was found with stuck-on and smeared brown debris, and the supply cabinet had black-spotted debris on the inside walls, indicating a lack of cleanliness and maintenance. The facility also failed to provide a home-like dining environment in the locked memory care unit's dining room. Observations showed that residents in this unit were served meals on trays placed on dining tables, which contrasted with the main dining room where meals were served directly on the table without trays. Interviews with staff, including the Dietary Director, DON, and a CNA, revealed a lack of awareness and understanding of why meals were served differently in the locked memory care unit. The facility's policy emphasized creating a pleasant dining atmosphere, which was not adhered to in the memory care unit, potentially leading to an institutionalized dining experience for residents.
Failure to Notify Provider of Missed Medication Doses
Penalty
Summary
The facility failed to maintain professional standards of nursing practice by not notifying the provider of missed medication doses for two residents. Resident #6, who was admitted with atrial fibrillation, missed a morning dose of Symbicort inhaler because the medication was not reordered in time. The LPN responsible did not notify the facility's medical doctor, believing it was unnecessary. This oversight was attributed to a common issue where staff were not diligent in reordering medications, leading to missed doses. Resident #338, admitted with hypertension and a PEG tube, also experienced missed medication doses. Upon readmission, the facility did not have the resident's medications available, including Coreg, due to a failure in ordering them. Additionally, there were no feeding tube orders in place, resulting in missed flushes for the PEG tube. The LPN involved did not verify the orders with a second nurse, as required, and the Unit Manager was not informed of the missing orders. Interviews with facility staff, including the DON and pharmacists, revealed systemic issues with medication reordering and communication. The facility's policy required nurses to reorder medications when there were 7 doses remaining and to notify providers of missed doses, but these procedures were not consistently followed. The pharmacy confirmed that urgent medications could be delivered the same day if requested, but this option was not utilized, leading to the deficiencies observed.
Failure to Provide Adequate Grooming for Residents with Cognitive Impairments
Penalty
Summary
The facility failed to provide adequate grooming care for four residents who were dependent on staff for activities of daily living, resulting in unkempt appearances and potential feelings of embarrassment. Observations revealed that these residents, all with severe cognitive impairments, had noticeable facial hair that was not addressed by the staff. Despite the facility's policy to improve residents' appearance in accordance with their preferences, there was no documentation to explain why the grooming was not performed. Resident #12 was observed multiple times with long white facial hairs on her chin, and no documentation was provided to justify the lack of shaving. Similarly, Resident #14 had facial hair resembling a mustache and chin hairs, with a family member confirming that the resident would not have wanted facial hair. Resident #17 had a visible mustache and debris in her hair, while Resident #53 had long chin hairs. All these residents were observed over several days with the same grooming issues. Interviews with staff, including the Director of Nursing and a Registered Nurse, revealed a lack of awareness regarding the residents' preferences for facial hair grooming. The staff prioritized completing baths over addressing facial hair, and there was no documentation of refusals or preferences for grooming. The facility's shaving policy, adopted in 2018, emphasized improving residents' appearance according to their preferences, but this was not adhered to in these cases.
Failure to Provide Resident Food and Beverage Preferences
Penalty
Summary
The facility failed to consistently provide residents with their food and beverage preferences, leading to incorrect items being served to 12 residents out of a census of 88. Observations revealed that residents were often given beverages and nutritional supplements that did not match their meal ticket preferences. For instance, Resident #17 was repeatedly served a red beverage instead of apple juice and a Vanilla Ensure Plus instead of Chocolate Boost, which was specified on her meal ticket. Similarly, Resident #53 and others were served Ensure Plus instead of Boost, despite the nutritional differences between these products. In several instances, residents were served meals that did not align with their documented preferences or dietary needs. Resident #2, who preferred sweet breakfasts, was served only one portion of French toast instead of the double portion noted on her meal ticket. Resident #64, who disliked broccoli, was served it despite her meal ticket specifying alternative vegetables. Additionally, Resident #24, a diabetic, was served regular jam instead of the sugar-free condiments she preferred, and was given oatmeal instead of Fruit Loops on a day when Fruit Loops were requested. Interviews with staff, including the Dietary Director, revealed that the discrepancies were due to the dietary department providing what was available rather than what was preferred or ordered. The Dietary Director acknowledged that the facility's policy was to provide substitutes from the same food group and nutritionally equivalent, but this was not consistently followed. The report highlights that the residents in the locked memory care unit were unable to express their dissatisfaction, which could impact their nutritional intake.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by the interactions between staff and residents. Resident #54, who was cognitively intact with a BIMS score of 15/15, reported overhearing CNAs making derogatory comments about a resident's hygiene, which she found upsetting. Despite reporting this to the Unit Manager (UM) CC, no thorough investigation was conducted to address the issue or identify the resident involved. Interviews with staff revealed a lack of communication and follow-up on the reported concerns. Social Services Director (SSD) GG admitted to not investigating Resident #54's previous complaints, assuming they were being handled by the nursing team. UM CC acknowledged speaking to the CNAs about keeping their voices down but did not report the incident to higher management or investigate further. The Assistant Director of Nursing (ADON) was aware of the complaint but did not pursue it, believing UM CC had resolved the issue. The Director of Nursing (DON) was unaware of the incident until the survey, indicating a breakdown in communication and reporting within the facility. The facility also failed to provide grievance forms for Resident #54, suggesting a lack of documentation and follow-up on resident complaints. Previous issues with CNA P's behavior were noted, but no corrective actions were mentioned in the report.
Failure to Update Advanced Directive and Code Status
Penalty
Summary
The facility failed to ensure that Resident #338's advanced directive information was updated and accurate, which could potentially lead to the resident's preferences for medical care not being followed. Resident #338 was admitted with a diagnosis of hypertension and had designated a family member, FM RR, as their patient advocate. The resident had signed a form indicating they did not want life-sustaining treatment under certain conditions. However, despite being listed as a Full Code at the facility, FM RR had requested a change to Do Not Resuscitate (DNR) status, which was not processed by the facility. FM RR, who was responsible for making medical decisions due to the resident's inability to participate in complex decision-making, expressed difficulty in fulfilling this role due to living in another state. FM RR had informed the facility of the desire to change the code status to DNR and later requested the facility to obtain a guardian for the resident. Despite these requests, the facility did not send the necessary paperwork to FM RR to change the code status, nor did they initiate the process for guardianship. The Social Services Director confirmed awareness of these issues but could not explain why the paperwork was not sent or why the guardianship process was not started.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for a resident who was moderately cognitively impaired with diagnoses of dementia and Alzheimer's disease. On March 15, 2025, a progress note indicated that the resident had bruising and swelling on the labia and a laceration above the urethra, discovered during a catheterization procedure. Despite these findings, the nurse on duty did not inform the family or emergency contact. The Assistant Director of Nursing was informed, but the family was still not contacted. The Director of Nursing confirmed that the resident's emergency contact was not notified of the bruising and tear when they were found.
Misappropriation of Resident's Narcotic Medications
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medications for a resident, resulting in the loss of the resident's pain medication. The issue was identified when the Director of Nursing (DON) received a call from the facility pharmacy about a discrepancy involving 20 unaccounted Percocet pills prescribed to a resident. An audit of medication carts and narcotic drawers was conducted, but the missing medication could not be located. The investigation revealed that a Registered Nurse (RN) had signed for a new Norco prescription for the resident but failed to add it to the narcotic count sheet, which should have reflected 35 scripts instead of 34. The RN was the last to document the administration of Percocet to the resident and tested positive for opioids and oxycodone during a drug test. Despite providing an undated script for Norco, the RN could not explain the missing narcotic card and narcotic sheet or why the Norco script was not logged onto the shift-to-shift count sheet. The facility concluded that the RN had diverted the Percocet from the resident, as she was unable to provide a valid prescription for oxycodone and did not follow procedure with the addition of the Norco script to the narcotic count log. The investigation included interviews with the RN and a Licensed Practical Nurse (LPN), as well as a review of the narcotic count logs and medication administration records. The Consulting Pharmacist confirmed the discrepancies in the documentation and noted that the RN had signed for the delivery of the Norco prescription and was the last to document the administration of Percocet. The facility's disciplinary action report for the RN indicated a previous violation of department policies and procedures related to medication documentation.
Failure to Report Observations of Potential Abuse
Penalty
Summary
The facility failed to operationalize its abuse policy and procedure for a resident who was moderately cognitively impaired with diagnoses including dementia and Alzheimer's disease. The deficiency occurred when staff did not report observations of potential sexual abuse to the Nursing Home Administrator immediately. On a specific date, a progress note indicated that the resident had bruising and swelling in the genital area, which was not reported to the Administrator as required by the facility's policy. The Nursing Home Administrator only became aware of the injury weeks later when informed by the Assistant Director of Nursing. Interviews with staff revealed that the Licensed Practical Nurse who observed the injury did not report it to the Abuse Coordinator but instead informed the oncoming nurse. The Registered Nurse who also observed the injury did not notify the Administrator or the Abuse Coordinator, only discussing it with the Assistant Director of Nursing. The facility's policy mandates that all allegations and suspicions of abuse must be reported immediately to the Administrator or their designee, which was not followed in this case. The facility's abuse training records showed that the involved staff had received training on reporting requirements, yet failed to adhere to them.
Failure to Update Care Plan for Fall Prevention
Penalty
Summary
The facility failed to update and revise the person-centered care plan in a timely manner with appropriate interventions for the prevention of falls for a resident. The resident, a male with diagnoses including lack of coordination, muscle weakness, dementia, and Alzheimer's disease, was identified as being at high risk for falls. Despite this, the care plan did not include necessary interventions such as the use of a fall mat, which was not consistently placed by the resident's bed as required. The resident experienced multiple falls, including one incident where he was found on the floor after attempting to self-transfer from bed to wheelchair. Observations revealed that the fall mat, which was supposed to be a part of the resident's fall prevention strategy, was not in place during these incidents. Interviews with staff, including a CNA and an LPN, confirmed that the fall mat was not listed as an intervention in the resident's care plan or kardex, indicating a lack of communication and documentation. The Director of Nursing (DON) acknowledged the oversight and noted that the interdisciplinary team met weekly to review falls and care plans, but the necessary updates had not been made for this resident. The failure to include and implement the fall mat intervention in the care plan contributed to the resident's repeated falls, highlighting a deficiency in the facility's care planning and communication processes.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to provide necessary care and services to prevent, treat, and promote healing of pressure ulcers for a resident with multiple pressure ulcers and chronic venous hypertension. The resident had several pressure ulcers, including a stage 3 ulcer on the right buttock, an unstageable ulcer on the left ankle, and a stage 3 ulcer on the left heel. Despite having a care plan that included interventions such as the use of bilateral boots for offloading pressure, these interventions were not consistently implemented. Observations revealed that the resident was often left in a supine position without the prescribed bilateral boots for offloading, which were intended to prevent further skin breakdown. The resident reported that staff had not assisted her in getting out of bed since her admission and that she was not taken to the bathroom despite being continent. The resident's legs and feet were frequently observed without the necessary offloading devices, and her wounds were not properly managed, as evidenced by purulent drainage and multiple open sores on her lower legs. Interviews with staff indicated a lack of adherence to the care plan, as the intervention for bilateral boots was not documented in the resident's kardex, and staff failed to apply the boots consistently. The Medication Administration Record/Treatment Administration Record (MAR/TAR) inaccurately indicated that the boots were applied, despite observations to the contrary. The facility's failure to implement the care plan and document refusals or changes in the resident's condition contributed to the deficiency in pressure ulcer care.
Failure to Use Assistive Devices Leads to Resident Falls
Penalty
Summary
The facility failed to ensure the safety of Resident #33, who has a high risk for falls due to multiple health conditions, including the absence of a right leg above the knee, multiple sclerosis, blindness in the left eye, and muscle wasting. The resident's care plan indicated the use of a slide board for transfers, but this was not consistently followed by the staff. On two separate occasions, the resident was found on the floor after attempted transfers by a CNA, indicating a lack of adherence to the prescribed safety measures. On the first incident, the CNA attempted to pivot transfer the resident from the bed to a wheelchair without the resident's assistance, resulting in the resident sliding to the floor. The CNA reported using a gait belt, but the resident was described as dead weight and did not assist during the transfer. The bed was positioned higher than the wheelchair to facilitate a safe transfer, but the lack of proper technique and assistive device use led to the fall. In the second incident, the resident explicitly stated that the CNA did not use the slide board and attempted to lift him independently, which resulted in the resident being lowered to the floor. The resident reported that the slide board was usually placed against the footboard of his bed, but it was not utilized during the transfer. Despite the CNA having completed training for fall prevention and the use of assistive devices, the failure to follow the care plan and use the slide board contributed to the resident's fall risk and subsequent incidents.
Failure to Provide Timely Emergency Physician Services
Penalty
Summary
The facility failed to ensure that emergency physician services were utilized for a resident who was moderately cognitively impaired and had multiple diagnoses, including morbid obesity, anxiety disorder, metabolic encephalopathy, COPD, and chronic respiratory failure. After returning from a hospital stay, the resident had not voided for approximately 13 hours, and facility staff made several attempts to contact the resident's physician and the facility's on-call medical provider without success. The facility's nurse practitioner was unable to provide an order for catheterization because the resident was not under their care. The Director of Nursing acknowledged that there was no plan in place for residents under the care of the independent physician if he did not respond to calls. The resident eventually received a straight catheterization, which relieved 600cc of urine, indicating significant urinary retention. The lack of timely physician response and the absence of a contingency plan for emergency care contributed to the deficiency, as the resident did not receive prompt medical intervention for a potentially serious condition.
Medication Administration Errors Result in 12% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 12% error rate. This deficiency was observed in two residents. Resident #338, who was readmitted to the facility, did not receive the correct dosage of Depakote due to an incomplete medication order that lacked a specified dose. The LPN administered a 125 mg dose instead of the prescribed 500 mg. Additionally, the morning dose of Coreg was omitted because it was not available. The LPN documented the administration of Depakote under an order that did not specify the dose, which was confirmed by the DON during a review of the MAR. The DON acknowledged the error and confirmed that the LPN did not follow the rights of medication administration. Resident #6 did not receive the morning dose of Symbicort inhaler because it was not available, as it had not been reordered. The LPN noted the absence of the inhaler and omitted the dose. The facility's policy requires that medications be administered as prescribed by the attending physician, and any discrepancies in dosage or schedule should be verified against the physician's orders. The failure to adhere to this policy contributed to the medication errors observed.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to properly label, date, and store medications in the medication cart, as observed during a survey. An opened insulin lispro (Humalog) pen was found in the top shelf of the cart without the date it was opened, although it was labeled with the resident's name. Additionally, in the stock medications area of the cart, an opened bottle of Mucus ER and an opened bottle of Cetirizine 10 mg were found without open dates. Registered Nurse (RN) FF confirmed that the nurses were supposed to label the insulin pens and other medications with the date they were opened, but this was missed. The Director of Nursing (DON) reported that the night shift nursing staff were expected to review the medication carts to ensure all medications were labeled with open dates, and that nurses should label medications when they are opened. This oversight in labeling and dating medications could potentially lead to decreased efficacy of medications and exacerbate medical conditions.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to effectively implement Enhanced Barrier Precautions (EBP) for two residents, R7 and R338, which resulted in potential cross-contamination risks. For R7, the medical records indicated the presence of a urinary catheter, but there was no documentation of EBP being implemented until several days after the catheter was inserted. Observations revealed that there was no signage or personal protective equipment (PPE) available at R7's room, and staff, including the Unit Manager, handled the catheter tubing without wearing gloves or gowns. The Director of Nursing later confirmed that R7 should have been placed on EBP due to the urinary catheter. For Resident #338, who had an enteral feeding tube, there was a sign indicating the need for EBP, but staff did not consistently adhere to these precautions. A Certified Nursing Assistant was observed assisting the resident without wearing a gown, despite the requirement for both gloves and gowns for direct care activities. An LPN confirmed that the resident was on EBP due to the feeding tube, highlighting a lapse in adherence to infection control protocols.
Failure to Prevent Elopement and Ensure Safe Transfers
Penalty
Summary
The facility failed to ensure the safety and prevent elopement for three residents, resulting in Immediate Jeopardy. Resident #100 and Resident #101 left the premises without staff knowledge and were later found in the community. Resident #100, who had a history of expressing a desire to leave the facility, was not reassessed for elopement risk despite showing signs of exit-seeking behavior. The facility's elopement policy was not followed, as door alarms were not functioning properly, and staff were not immediately responsive to alarms. Resident #101, who had a known history of elopement risk, was found outside the facility without staff knowledge, indicating a failure in monitoring and supervision. Additionally, the facility failed to minimize the risk of injury during mechanical lift transfers for Resident #106. The resident fell during a transfer when the sling clips became detached from the lift, resulting in a head injury. The facility did not conduct routine inspections of the mechanical lift slings, and the sling used did not have a manufacturer's tag, making it impossible to determine its age or condition. The CNA involved in the transfer was not aware of the requirement for two staff members to assist with transfers, further contributing to the incident. The facility's inaction in maintaining proper safety protocols and equipment checks led to these deficiencies. The lack of reassessment for elopement risk, failure to ensure door alarms were functioning, and inadequate training and equipment maintenance for mechanical lift transfers were significant factors in the incidents involving Residents #100, #101, and #106.
Removal Plan
- All licensed nurses present in the facility were re-educated on warning signs of elopement, reassessing residents to determine their risk of elopement and development of an elopement care plan and communicating new resident needs related to elopement to the interdisciplinary team. Non licensed staff were educated on resident warning signs for elopement and need to report signs to the nurse immediately.
- Plan put in place to educate every staff member prior to their next working shift.
- Facility confirmed all at risk residents had a care plan to address their needs related to their risk of elopement as well as a functioning personal alarm.
- Facility confirmed all door alarms and personal safety alarms were in working order and were monitored for functionality daily.
- Resident #101 was placed on 15-minute checks until a personal safety alarm was placed on him.
- Facility ensured the door codes were changed.
- Facility ensured elopement drills will be conducted on a weekly basis.
- Facility ensured signs were posted to educate visitors on the need to avoid assisting any resident through a door and to have staff escort visitors out of the building.
- Facility ensured the elopement book was reviewed and up to date.
- Facility reviewed the elopement policy and deemed it was appropriate.
- Facility ensured all windows were functioning properly.
- Facility ensured behavior tracking orders for elopement tendencies were added to all residents at risk.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents involving four residents. Resident #102, who was severely cognitively impaired, physically assaulted Resident #103. Despite having a care plan in place to manage potential aggression, Resident #102 exhibited wandering, abusive language, and threatening behavior prior to the assault. The incident occurred when Resident #102 struck Resident #103 multiple times, causing emotional distress and physical pain. Staff intervention was delayed, and Resident #103 was left emotionally upset and physically bruised. In another incident, Resident #107, also severely cognitively impaired, engaged in inappropriate sexual behavior by grabbing Resident #108 in the dining room. Resident #107 had a history of socially inappropriate behavior, yet the care plan interventions were insufficient to prevent the incident. Resident #108, who was moderately cognitively impaired, experienced significant emotional distress and fear following the incident, leading her to request a change in her living arrangements to avoid further encounters with Resident #107. The facility's failure to implement effective interventions and monitor residents' behaviors contributed to these incidents of abuse. The facility's policy on abuse and neglect was not adequately enforced, as evidenced by the lack of preventive measures and timely staff response to the residents' aggressive and inappropriate behaviors. These deficiencies highlight the facility's inability to maintain a safe environment free from abuse for its residents.
Failure to Follow Post-Fall Protocols
Penalty
Summary
The facility failed to ensure proper post-fall care and assessment for a resident, resulting in the potential for serious injury. The facility's policy required that a resident not be moved until a nurse evaluated their condition after a fall. However, after a resident fell from a mechanical lift and sustained a head injury, a Certified Nursing Assistant (CNA) panicked and moved the resident back to bed without waiting for a nurse's assessment. This action was contrary to the facility's policy and the guidelines published by the American Association of Post-Acute Care Nursing, which emphasize the importance of assessing for spinal column injuries and other significant injuries before moving a resident. The resident involved had a history of cerebral infarction, major depressive disorder, unspecified dementia, and anxiety disorder, and required maximal assistance for transfers. After the fall, the resident was sent to the hospital and returned with stitches and a hematoma. Interviews with staff confirmed that the resident was moved before a proper assessment was conducted, which could have worsened the injuries. The Director of Nursing reiterated the importance of leaving a resident in the position they were found until assessed by a nurse to prevent complications.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to adhere to the care plan for a resident, resulting in an injury. The resident, who was severely cognitively impaired and had limited physical mobility, was supposed to be transferred using a sit-to-stand lift as per her care plan. However, a CNA attempted to transfer the resident from her bed to a wheelchair without using the recommended equipment or a gait belt. During this manual transfer, the resident sustained a laceration on her right lower leg, which required sutures. The incident occurred when the CNA responded to the resident's call to go to the bathroom. Without checking the care plan, the CNA stood the resident up and twisted her into the wheelchair, leading to the injury. The CNA admitted to not using the sit-to-stand lift or a gait belt during the transfer. The Director of Nursing confirmed that the transfer was conducted incorrectly, as the sit-to-stand lift should have been used according to the care plan.
Failure to Notify Physician After Resident Falls
Penalty
Summary
The facility failed to immediately notify the resident's physician of a change in condition for a resident who experienced two unwitnessed falls with known head trauma. The resident, who had been admitted to the facility with dementia, fell twice on the same night. The first fall was documented by a registered nurse, who noted the resident was found kneeling with their forehead on the floor, but vital signs were stable and the resident denied pain. The resident was then placed in a wheelchair and moved to a common area for observation. Shortly after, the resident fell again, resulting in a raised bump on the right temple. Despite these incidents, the facility did not notify the resident's physician. Interviews revealed that the facility staff believed it was the responsibility of the hospice nurse to communicate with the hospice physician, as the resident was a hospice patient. However, the hospice nurse reported that the facility declined an offer for a nurse visit to examine the resident after the falls. The hospice nurse also indicated that the facility nurse was expected to contact the resident's physician directly. A follow-up visit note from the resident's provider did not mention the falls, indicating a lack of communication and assessment regarding the resident's condition after the incidents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, specifically involving two residents, Resident #104 and Resident #105. Resident #105, who has a history of dementia and psychosis, was involved in two incidents of physical aggression towards Resident #104 within an eight-day period. The first incident occurred when Resident #105 placed her hands on Resident #104's shoulders and squeezed them, reportedly because Resident #104 was making comments about her. The second incident involved Resident #105 bending back Resident #104's fingers, resulting in redness and pain, although an X-ray showed no fractures. Resident #105's care plan indicated a potential for physical aggression due to cognitive impairments and poor impulse control. Despite interventions such as providing a private room and activities to keep her engaged, there was a lack of consistent supervision and interaction, particularly from the activities department. Observations noted that Resident #105 was often left alone in her room without engagement, and staff were not always present to intervene during incidents. Resident #104, also diagnosed with dementia, was known to make inappropriate comments, which often triggered Resident #105's aggressive behavior. Staff interviews revealed that there was insufficient dementia-specific training and a lack of adequate supervision, especially during weekends and evenings. The facility's failure to ensure consistent supervision and effective interventions contributed to the repeated incidents of resident-to-resident abuse.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to recognize and report an injury of unknown origin for a resident, resulting in a lack of timely reporting and potential delay in investigation. The resident, who had dementia, was admitted to the facility and later complained of right hip pain. An X-ray revealed an impacted intertrochanteric fracture with varus deformity. Despite the fracture being identified, the facility did not report it as an injury of unknown origin because they attributed it to a fall that occurred earlier. The Director of Nursing (DON) and Nursing Home Administrator (NHA) both indicated that the fracture was linked to a fall on the resident's right side. However, there was no documentation of a post-fall assessment or evidence showing when the interdisciplinary team determined the fracture was due to the fall. The incident report from the fall noted no immediate pain or discomfort, and subsequent notes indicated no changes in the resident's condition until the pain was reported two days later. Interviews with staff revealed that the resident initially showed no signs of injury or pain following the fall. The resident's records showed stable vital signs and no pain complaints immediately after the incident. The fracture was only identified after the resident experienced pain and difficulty walking, leading to an X-ray. The facility's delay in correlating the fracture to the fall and lack of immediate reporting to the state contributed to the deficiency.
Incomplete Post-Fall Assessment Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation of post-fall assessments for a resident, leading to potential insufficient follow-up and lack of necessary interventions. The resident, who had been admitted with a diagnosis of dementia, experienced two falls on the same night. The first fall was documented in the nurse's notes, indicating that the resident was found kneeling with their forehead touching the floor, with stable vital signs and no pain reported. The resident was then placed in a wheelchair and moved to a common area for observation. Shortly after, the resident fell again, resulting in a raised bump on the right temple. Despite these incidents, the post-fall neurological check record indicated no abnormalities or changes in the resident's range of motion. However, the Director of Nursing (DON) later reported that a post-fall nursing assessment had not been documented in the resident's health record. This lack of documentation led to a delay in identifying a hip fracture, which was discovered when the resident complained of right leg pain and was unable to bear weight two days after the falls. The deficiency highlights the importance of accurate and complete medical documentation to ensure proper follow-up and intervention.
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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