Corewell Health Rehabilitation & Nursing Center -
Inspection history, citations, penalties and survey trends for this long-term care facility in Stevensville, Michigan.
- Location
- 4368 Cleveland Ave, Stevensville, Michigan 49127
- CMS Provider Number
- 235164
- Inspections on file
- 21
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Corewell Health Rehabilitation & Nursing Center - during CMS and state inspections, most recent first.
A resident with Alzheimer's dementia and a history of falls was prescribed lorazepam without adequate indication, monitoring, or consent. After starting the medication, the resident experienced multiple falls, culminating in a severe fall that caused pelvic fractures and death. The facility did not review the medication's role in the falls, failed to monitor for adverse effects, and did not obtain required consent, leading to significant harm.
A resident with dementia, left-sided paralysis, and chronic pain, who preferred to stay up late, was forced by staff to go to bed despite her resistance. During the process, she became agitated and combative, leading to multiple staff interventions. After being transferred to bed, the resident complained of severe left shoulder pain, and was later diagnosed with a fractured humerus. Staff interviews confirmed that her preferences were not honored, and her right to self-determination was not supported, resulting in frustration, an altercation, and injury.
A resident with Alzheimer's dementia and related conditions was administered Lorazepam without documented informed consent from their representative. The care plan lacked interventions for psychotropic medication use, and facility staff could not provide evidence of written or verbal consent, resulting in the resident's representative being unaware of the medication administration.
A resident with dementia and high fall risk did not consistently have a fall mattress properly placed next to the bed as required by the care plan and facility policy. Staff failed to ensure the intervention was in place, with interviews revealing miscommunication and lapses in following procedures, resulting in the resident being left without the intended fall protection.
Two residents with indwelling catheters were observed with catheter tubing and drainage bags in contact with the floor, contrary to facility policy. One resident's catheter bag was found resting on the floor while in bed, and another resident was seen self-ambulating with catheter tubing and a privacy bag dragging on the ground. Both residents had medical histories that increased their risk for infection, and one had recent evidence of a urinary tract infection.
The facility failed to maintain professional standards for food safety, with issues including debris accumulation in kitchen equipment, improper food storage, and inadequate temperature control. The ice machine and microwave were found with debris, and utensil drawers were not clean. Food items were improperly stored, with soy sauce not refrigerated and dish machine temperatures below required levels. Additionally, leftover food was not cooled or stored correctly, posing a risk of foodborne illness.
The facility was cited for deficiencies in its infection prevention and control program, including inadequate water management and improper hand hygiene practices. Maintenance staff were unaware of regular flushing procedures, leading to discolored water in several areas. Additionally, staff failed to use proper PPE during resident care, such as G-tube medication administration and incontinence care, increasing the risk of cross-contamination.
The facility failed to document advance directives accurately for three residents, leading to potential non-compliance with their medical care preferences. A resident had a DNR order without signed paperwork, another had incomplete documentation with a DNR form signed by the wrong advocate, and a third had a DNR order without signed documentation from the resident and physician. The social worker and nursing home administrator acknowledged the documentation issues.
A resident with multiple health conditions was found in a room with a heavily soiled mattress and damaged walls, indicating a failure to maintain a clean and safe environment. Interviews with staff revealed communication and follow-up issues regarding maintenance and cleanliness, with no evidence of completed work orders and insufficient maintenance personnel.
The facility failed to transmit MDS discharge assessments timely for two residents, leading to potential inaccuracies in discharge tracking. One resident's assessment was incomplete with sections GG, J, M, N, O, and P pending, while another's had section K pending. An MDS nurse confirmed the assessments should have been completed and transmitted by specific dates.
A facility failed to complete a PASARR Level II assessment for a resident with severe cognitive impairment and mental health diagnoses, despite the need being identified in a Level I assessment. The social worker could not provide documentation of the Level I assessment or a completed Level II assessment, resulting in potential unmet mental health care needs.
A facility failed to develop a Hospice care plan for a resident with dementia and Alzheimer's disease, who had a severely impaired cognitive status and was receiving Hospice care. The MDS nurse misunderstood the responsibility for completing the care plan, leading to a deficiency in person-centered care planning.
A resident with severe cognitive impairment and dependence on staff for ADLs was observed with long, dirty fingernails, indicating a failure in nail care provision. Despite the resident's preference for clean nails, staff inconsistently provided care, with some CNAs stating it should be done during showers. An LPN acknowledged the need but did not complete the task due to time constraints. The DON expected nails to be clean, but there was no documentation of care, leading to the deficiency.
A resident with CHF and a pacemaker was not administered Lasix as ordered upon admission to the facility, leading to significant weight gain and worsening of his condition. Despite attempts to communicate the need for the medication, it was not consistently provided, resulting in hospitalization for fluid overload. The facility failed to report significant weight changes to the physician or adjust the diuretic medication, contributing to the resident's deteriorating condition.
Two residents at risk for pressure injuries did not receive adequate preventative care in a facility. One resident, with a history of pressure injuries, was often improperly positioned in a wheelchair without secure pressure-relieving boots, leading to a pressure ulcer on the heel. Another resident spent extended periods in a wheelchair without a pressure-reducing cushion, contrary to their care plan. Staff interviews confirmed these deficiencies, highlighting a failure to adhere to care plans and professional standards for pressure ulcer prevention.
The facility failed to control hot water temperatures, allowing them to exceed safe limits, and did not ensure safe transfers for two residents. One resident was transferred without a gait belt or additional staff, while another was transferred with an improperly attached hoyer sling, risking their safety.
Two residents with indwelling foley catheters did not receive proper care, leading to potential risks of catheter dislodgement, pain, and infection. One resident was not toileted as per her care plan and had an unsecured catheter causing discomfort. Another resident's catheter was not secured, and incontinence care was performed without changing gloves after contact with feces, risking cross-contamination. These deficiencies were observed during staff interviews and direct observations.
A resident with COPD was found with an empty water bottle on her oxygen concentrator, which was still running. The oxygen tech reported a delay in scheduled maintenance, and facility staff had differing views on who was responsible for monitoring the equipment. This led to a deficiency in ensuring proper maintenance of the oxygen delivery system.
A facility failed to ensure a physician documented review and follow-up on pharmacy recommendations for a resident, leading to potential medication side effects and unnecessary medications. The resident had several pharmacy recommendations, including changes to Lidoderm orders, re-evaluation of duplicate therapy, and adjustments to insulin and Zoloft dosages, which were not addressed by the physician. The facility's policy required timely action on pharmacy reports, but the physician's response was left blank, indicating a deficiency in medication management.
Surveyors observed that the facility did not have a battery back-up light installed in the electrical room containing the generator Automatic Transfer Switch (ATS), as required by NFPA 110. This deficiency was confirmed with the Maintenance Technician and could impact access to emergency equipment during a generator failure.
Surveyors found that doors to the Therapy storage closet and a back hall storage closet used for emergency food and water did not self-close to a positive latch as required by LSC 19.3.2.1. These deficiencies were confirmed during interviews with the Maintenance Technician and could potentially affect 20 occupants if a fire were to occur.
A smoke barrier door near a resident room was found to be improperly aligned, causing it to bind on the floor and preventing it from self-closing or releasing when the fire alarm was activated. This issue was confirmed by the Maintenance Technician during the survey.
A resident with a history of dysphagia and choking incidents died after choking on food due to inadequate supervision and safety measures. Despite being on a specialized diet, the resident chose to eat foods not suitable for his condition. The facility failed to enforce the care plan requiring communal dining for supervision, especially during a COVID-19 outbreak when the main dining room was closed. Staff were unaware of the need for increased supervision, leading to the resident's death from choking.
Failure to Monitor and Prevent Unnecessary Psychotropic Medication Use Resulting in Resident Harm
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications without adequate indication and failed to monitor a resident for adverse effects after initiating such medication. A female resident with severe late-onset Alzheimer's dementia, a history of recurrent falls, insomnia, and depression was prescribed lorazepam daily. Prior to the prescription, the resident had not experienced any falls since her admission in February. After starting lorazepam, the resident experienced multiple falls in May, with no major injuries initially, but there was no evidence that the facility reviewed her medications or monitored for adverse consequences following these incidents. Documentation revealed that the resident's care plan identified her as being at risk for falls due to impaired balance and the use of psychoactive medications, but there was no policy or clear intervention for visual checks or monitoring for medication side effects. Behavior logs and care plans did not show a focus on monitoring psychotropic medications, and there was no documented increase in wandering or agitation prior to the medication change. The resident's family was not informed or asked for consent regarding the addition of lorazepam, and there was no documentation of consent for the medication. Staff interviews indicated that the resident was independent, not aggressive or combative, and could be redirected, with no significant behavioral escalation documented prior to the medication change. After the initiation of lorazepam, the resident experienced a significant fall resulting in an impacted acetabulum and pelvic fracture, leading to hospitalization and subsequent death. There was no indication that the facility reviewed the resident's medications after each fall to determine if they contributed to the incidents. The consultant pharmacist was not made aware of the increase in falls after the addition of lorazepam, and the facility's medication management policy was not effectively implemented to ensure monitoring and prevention of unnecessary drug use. The lack of monitoring, failure to obtain consent, and absence of medication review after falls directly contributed to the deficiency.
Removal Plan
- Review all residents' charts to identify residents on psychotropic medication to ensure adequate monitoring.
- Create worklist tasks for all residents on psychotropic medications to monitor for adverse reactions, specifying medication class and symptoms to monitor.
- Audit all residents on psychotropic medications for consent forms; complete consent forms for any resident missing one and obtain signature.
- Upload completed consent forms to Epic.
- Educate the Medical Director on F605 regulations, with emphasis on the appropriate use of psychotropic medications.
- Provide a list of all residents on psychotropics to the Medical Director.
- Educate the Nurse Practitioners on F605 regulations.
- Review behavior logs during the Interdisciplinary Team (IDT) meeting, including review of care plans for affected residents.
- Educate nurses regarding the requirement to implement non-pharmacological interventions prior to initiating psychotropics.
- Educate the social worker on the expectation to implement non-pharmacological interventions, and educate the second social worker.
- Re-educate nurses, led by the DON, for all nursing leaders and on-duty staff; do not permit any nurse to work until this education is completed.
- The DON or designee will pull an Epic report to identify newly prescribed psychotropics and verify that consent forms and monitoring tasks are in place.
- Review new symptoms during the IDT meeting and communicate to providers using the SBAR format.
- Educate social workers on obtaining consent for psychotropic medications; re-educate one social worker and re-educate the second.
- Educate the consultant pharmacist on the medication review process and confirm understanding.
Failure to Honor Resident's Right to Bedtime Choice Results in Injury
Penalty
Summary
A resident with a history of chronic pain, left upper arm contracture, debility, stroke, left-sided paralysis, and dementia was reviewed for her right to self-determination and choice. The care plan noted that the resident may refuse to return to her room for incontinence care or go to bed at a reasonable time, with interventions to assess decision-making ability and provide a consistent routine. Despite this, staff attempted to put the resident to bed between 9:00 PM and 10:00 PM, although she was known to resist going to bed and preferred to stay up. During the process of undressing her and preparing her for bed, the resident became agitated, fought with staff, and began swinging her arm. Staff left the room to seek assistance, and multiple CNAs attempted to help, but the resident continued to resist and became increasingly upset. Subsequently, the resident was transferred to bed using a Hoyer lift by another CNA, during which she was observed to be crying and calling staff names. Later, the resident complained of severe pain in her left shoulder, which was assessed by nursing staff and found to be swollen and tender. She was sent to the emergency department, where imaging revealed a closed fracture of the surgical neck of the left humerus. The resident reported to staff and emergency personnel that her arm had been pulled during care, and she repeatedly stated that her arm was broken by staff. Staff interviews confirmed that the resident was typically resistive to going to bed and that her preferences were not accommodated on the night of the incident. Observations and interviews with staff and the resident indicated that her right to make choices about her bedtime and care routine was not honored. Staff acknowledged that the resident preferred to stay up late and often refused to go to bed, but on the night in question, they proceeded with care despite her resistance. The failure to respect the resident's choices and to re-approach her at a later time contributed to her agitation and the subsequent altercation, which resulted in a significant injury.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for one resident with severe late onset Alzheimer's dementia, agitation, insomnia, and depression. Review of the resident's care plans showed no focus or interventions related to the use of psychotropic medications or monitoring for adverse consequences. Multiple orders for Lorazepam were present in the resident's record, but there was no documented consent for these medications, either written or verbal. The resident's family member and Durable Power of Attorney (DPOA) was not aware that the resident was receiving Lorazepam and reported not having given permission for its use. Interviews with facility staff revealed that the process for obtaining and documenting consent was inconsistent and lacked a standard procedure. The social worker was unable to locate any notes indicating that consent had been obtained for the prescribed Lorazepam, and the nurse liaison confirmed there was no documentation of verbal consent in the resident's record. The absence of proper documentation and communication resulted in the resident or their representative not being fully informed or able to make decisions regarding the risks, benefits, and alternatives to the prescribed psychotropic medication.
Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement care plan interventions and follow facility policy to prevent falls for a resident with dementia, confusion, incontinence, reduced mobility, and end-stage Alzheimer's disease. The resident was identified as a fall risk, and the care plan included interventions such as keeping the bed in a low position, placing a fall mattress next to the bed, and conducting regular visual checks. Despite these interventions being documented, staff did not consistently ensure the fall mattress was properly positioned next to the bed as required. On one occasion, a CNA observed the resident attempting to get out of bed and sliding to the floor, after which additional fall prevention measures were added, including placing one side of the bed against the wall and using a full-thickness mattress on the open side. However, during a later observation, the fall mattress was found standing on its side rather than lying flat on the floor next to the bed. Staff interviews revealed that the CNA forgot to lay the mattress down after removing the resident's roommate, and the LPN assumed the CNA would do it, resulting in the intervention not being in place as intended. The facility's policy required that interventions to prevent falls be implemented and care plans updated as needed. Despite the resident's high risk for falls and the documented need for a fall mattress, staff failed to consistently follow the care plan and policy, leaving the resident without the required fall protection at the bedside. This lapse in following established interventions and policy contributed to the deficiency cited by surveyors.
Failure to Maintain Catheter Tubing and Drainage Bags Off the Floor
Penalty
Summary
The facility failed to prevent the risk of urinary tract infection by not ensuring that urinary catheter tubing and drainage bags were kept off the floor for two residents with indwelling catheters. One male resident with a history of stroke and gross hematuria was observed lying in bed with his catheter bag resting directly on the floor without a barrier. This was confirmed by an LPN, who subsequently placed a towel under the bag. The clinical nurse supervisor confirmed the resident had a Foley catheter, which had last been changed the previous month. A female resident with dementia, insomnia, and diabetes was observed self-ambulating in her wheelchair with her catheter bag in a privacy bag, but with approximately 12 inches of catheter tubing dragging on the floor. Multiple observations confirmed that both the tubing and the privacy bag containing the catheter bag were in contact with the floor as she moved around the facility. The urine in the tubing appeared dark yellow, orange-tinged, and cloudy. Staff interviews confirmed that this resident had recurrent urinary tract infections, and a recent urinalysis showed evidence of infection. Facility policy requires that catheter tubing and drainage bags be kept off the floor, but this was not followed in these cases.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The Certified Dietary Manager (CDM) revealed that maintenance staff and an external vendor were responsible for cleaning the ice machines. However, an inspection of the ice machine's dispensing spout showed a significant accumulation of black and brown debris. Additionally, the microwave in the main kitchen had a buildup of debris and chipping surfaces, and utensil drawers contained crumb debris. These conditions indicate a lack of proper cleaning and maintenance, which could lead to food contamination. Further observations revealed improper storage and temperature control of food items. An open gallon container of soy sauce was stored under a preparation table despite instructions to refrigerate after opening. The dish machine was not consistently reaching the required minimum wash temperature of 160°F, as evidenced by multiple cycles showing temperatures below this threshold. The CDM admitted that staff were not diligent in maintaining logs to ensure the dish machine's proper functioning, and the device used to test the machine was reportedly malfunctioning. The facility also failed to properly cool and store leftover food items. During a review of the walk-in cooler, items such as chili, creamy vegetable soup, and cooked pork loin were found at temperatures above the recommended 41°F. The CDM was unsure of the cooling methods used and decided to discard the items. A subsequent visit found a pan of pork gravy at 69°F, which was also discarded. These findings highlight a lack of adherence to FDA Food Code standards for cooling and storing food, potentially leading to foodborne illnesses among residents.
Plan Of Correction
Element #1 No specific Residents were identified in citation. Ice Machine and Dish Machine were serviced/cleaned by vendor, microwave was replaced. Utensil drawers were cleaned of debris, floor area behind ice machine has been cleaned. Soy Sauce disposed of at time of observation. Observed gallon of chili, vegetable soup and pork loin discarded at time of observation. Element #2 Residents residing in facility who have food prepared in the dietary department have potential to be affected. Element #3 Nutrition Services staff have re-educated on 2017 FDA food Code sections 4-601.11, Food Contact, Section 3-501.16 Time/Temp control for safety food hot/cold handling by CDM. Element #4 Nutrition Services Manager/designee will complete random weekly sanitation audits, cooling log and Dish Temperature audits. Variances will be addressed at the time of observation. Weekly audits to be forwarded to the facility QAPI committee for review and further recommendations. Element #5 The Administrator is responsible for sustained compliance.
Deficiencies in Infection Control and Water Management
Penalty
Summary
The facility was found to have deficiencies in its infection prevention and control program, specifically related to the management of water systems and hand hygiene practices. During a tour, it was observed that the facility lacked an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens in its plumbing system. Maintenance staff were unaware of regular flushing procedures for unused water fixtures, and brown, discolored water was observed in several areas, indicating a lack of routine flushing. Additionally, the facility did not have an active team overseeing the water management plan, and there was uncertainty about the permitting of the secondary treatment system. Infection control practices were also found to be lacking during resident care. For instance, a CNA was observed providing incontinence care to a severely cognitively impaired resident without changing gloves or performing hand hygiene between dirty and clean tasks. Similarly, an RN and an LPN failed to use proper PPE during G-tube medication administration and dressing changes for residents under enhanced barrier precautions. The RN did not change gloves or perform hand hygiene while handling various items and performing tasks, and the LPN did not wear a gown during medication administration, contrary to facility policy. The facility's infection control policy requires enhanced barrier precautions, including gown and glove use, during high-contact care activities. However, staff interviews revealed a lack of understanding and adherence to these precautions. The Director of Nursing and the Staff Educator/Infection Preventionist acknowledged the need for proper PPE use and hand hygiene but noted that glove use during incontinence care was not frequently audited. These deficiencies highlight significant lapses in infection control practices, increasing the potential for cross-contamination and disease transmission among residents.
Plan Of Correction
DSP A Element #1 No residents identified. Element #2 Residents residing in the facility have the potential to be affected. Front and Back 200 Spa rooms have been flushed to include tubs and commodes. Front and Back 100 soiled utility rooms have been flushed to include hopper sprayers. Element #3 Maintenance Technician and EVS supervisor have been re-educated on facility Water Safety and Management plan to include routine flushing and commissioning of portable water systems and Wednesday Water flushing protocols. Element #4 EVS/Designee to complete random weekly audit of required Wednesday flushing to include Spa and soiled utility areas. Variances will be addressed at the time of observation. Weekly audits to be submitted to the facility QAPI committee for review and further recommendations. Element #5 The Administrator is responsible for compliance. F880 DSP B Element #1 Residents #1, #29, #52, and #65, have had no adverse outcomes related to observations. Element #2 Residents residing in the facility have potential to be affected. Element #3 Licensed nursing staff have been reeducated on Infection Prevention and Control policy, including hand hygiene, peri care, enhanced barrier precautions, and g-tube care. Infection Control and prevention policy has been reviewed by DON and Administrator and deemed appropriate. All staff were re-educated on hand hygiene and enhanced barrier precautions. Element #4 Don/Designee will complete random weekly audits to ensure appropriate PPE, infection control practices including EBP, hand hygiene, peri care/catheter care, and g-tube care are followed. Variances will be addressed at the time of observation. Weekly audits to be submitted to the facility QAPI committee for review and further recommendations. ELEMENT #5 The Administrator is responsible for sustained compliance.
Incomplete Advance Directives Documentation
Penalty
Summary
The facility failed to accurately and completely document advance directives for three residents, leading to potential non-compliance with residents' medical care preferences. Resident #37 was admitted with a DNR order in the physician's orders, but there was no signed paperwork in the resident's chart confirming this status. The social worker was unsure if the resident was informed about the code status, and the resident himself was uncertain about his preference and whether he had signed any related documents. The nursing home administrator confirmed the absence of specific code status paperwork for this resident. Resident #312 had a DNR order, but the required documentation was incomplete. The DNR form was signed by the second advocate instead of the first, and there was no capacity form or two physician signatures to confirm the resident's inability to make decisions. The social worker acknowledged the missing documentation, and the nursing home administrator mentioned efforts to improve the process. Similarly, Resident #60 had a DNR order without signed documentation from the resident and physician. The social worker admitted that hospital discharge paperwork indicating a DNR status could not be used for the facility's DNR order and was unaware of the issue until it was brought to attention.
Plan Of Correction
Element #1: Resident #37, #312, and #60 Advanced Directives have been updated to reflect patient goals of care. Element #2: Residents that currently reside in the facility have potential to be affected. Element #3: Facility Social Workers have been re-educated on Michigan Do-Not-Resuscitate Procedure Act. Advanced Directives of residents currently residing in the facility have been audited; any identified concerns will be corrected in the moment. Element #4: Social Worker/Designee will complete 5 weekly Advanced Directive audits to ensure they meet requirements of the Michigan Do-not-Resuscitate Act and resident goals of care. Variances to be corrected at time of observation. Audits to be submitted to facility QAPI for review and further recommendations. Element #5: The Administrator is responsible for sustained compliance.
Facility Fails to Maintain Clean and Safe Environment for Resident
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for Resident #75, who had multiple health conditions including macular degeneration, legal blindness, dementia, diabetes, and kidney disease. Observations revealed that the resident's room contained a mattress on the floor next to the bed, which was heavily soiled with dried liquid stains, dried food, dusty shoe prints, and white dried material. Additionally, the room had significant damage to the walls, including gouges and missing paint, with exposed drywall and metal corner guards. Interviews with facility staff, including a CNA, RN, Housekeeping Manager, and Maintenance personnel, indicated a lack of effective communication and follow-up regarding maintenance and cleanliness issues. The CNA and RN reported that they would inform the nurse or environmental services about such issues, but there was no evidence of work orders being completed. The Housekeeping Manager acknowledged the responsibility for cleaning the mattress, while the Maintenance staff noted that funding for room repairs had not been secured. The maintenance staff also reported that they were the only maintenance personnel present, which may have contributed to the lack of timely repairs and maintenance in the resident's room.
Plan Of Correction
Element# 1 Medical equipment for resident #75 has been cleaned and sanitized. Gouges, dings, and dents on #75 wall have been repaired. Element# 2 Residents residing at the facility have the potential to be affected. All resident mattresses on the floor have been cleaned and sanitized. Facility Maintenance Technician/designee has audited facility resident rooms and work orders were placed for any rooms found with gouges, dings, and dents. Element #3 Environmental services have been educated on mattress cleaning protocol. Facility Maintenance technician has been re-educated on the process to track and retrieve work orders. Element #4 Environmental Services lead or designee(s), will conduct random weekly audits of medical equipment cleanliness and wall integrity. Audits will be forwarded to the facility QAPI committee for review and further recommendations. Element #5 The Administrator is responsible for sustained compliance.
Failure to Transmit MDS Discharge Assessments Timely
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) discharge assessments in a timely manner for two residents, resulting in the potential for inaccurate tracking of discharges. Resident #82 was discharged on 9/19/2024, but her MDS discharge assessment, with an assessment reference date (ARD) of 9/20/2024, was incomplete and not transmitted. The sections GG, J, M, N, O, and P were still in progress. Similarly, Resident #93 was discharged on 9/17/2024, and her MDS discharge assessment, with an ARD of 9/17/2024, was also incomplete and not transmitted, with section K still in progress. During an interview, MDS nurse D confirmed that the discharge assessments for both residents should have been completed and transmitted by specific dates in October 2024.
Plan Of Correction
Element 1: MDS discharge assessment for residents #82 and #93 were completed and transmitted. Element 2: Residents that discharge from the facility have the potential to be affected. The last 6 months of discharges have been reviewed for MDS completion and transmission. Identified concerns were addressed at time of observation. Element 3: MDS Nurses have been re-educated on encoding and transmitting data requirements of CMS. Element 4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s) will conduct random weekly audits of discharge MDS completion and submission. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5: The Administrator is responsible for sustained compliance.
Failure to Complete PASARR Level II Assessment
Penalty
Summary
The facility failed to ensure that a PASARR Level II assessment was completed for a resident, resulting in the potential for unmet mental health care needs. The resident, a female with diagnoses including recurrent major depressive disorder, dementia with behavioral disturbances, and bipolar affective disorder, was admitted to the facility and had a BIMS score indicating severe cognitive impairment. Despite the need for a Level II assessment being identified in the initial PASARR Level I assessment, no Level II assessment was found in the resident's electronic medical record. During an interview, the social worker reported that the PASARR Level I assessment was completed, indicating the need for a Level II assessment. However, the social worker could not produce a paper copy of the Level I assessment and confirmed that there was no completed Level II assessment or recommendation letter available on the OBRA website for the resident. The absence of a PASARR Level II assessment or recommendation letter was confirmed by the survey exit.
Plan Of Correction
Element #1 Resident #16 had a completed PASARR assessment. Resident was assessed for psychosocial well-being and found to be at baseline. Care Plan and Resident Care Summary reviewed and found to be appropriate to reflect resident care needs. Element #2 Residents residing in the facility have the potential to be affected. PASARR assessments for current residents were reviewed for timely completion. Any gaps identified have been addressed. Element #3 The facility Social Workers have been re-educated to the PASARR requirements. Element #4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Administrator, or designee(s), will randomly audit residents weekly to validate timely completion of PASARR assessments. The QAPI Committee will review findings and determine ongoing need for audits. Element #5 The Administrator is responsible for sustained compliance.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was receiving Hospice care, resulting in a deficiency. The resident, identified as Resident #58, was admitted with diagnoses including dementia and Alzheimer's disease and had a severely impaired cognitive status. A significant change in the resident's condition was noted, leading to the initiation of Hospice care. However, upon review, it was found that there was no Hospice care plan developed for the resident, which is a requirement for individualized care. During an interview, the MDS nurse revealed a misunderstanding regarding the responsibility for completing the Hospice care plan. The nurse initially believed that the Social Worker was responsible for this task, but later acknowledged that it was her responsibility. The facility's Care Planning and Coordination Policy mandates that each patient must have an individualized written plan of care, which was not adhered to in this case, leading to the potential for unmet care needs for the resident.
Plan Of Correction
Element #1 Residents #58 no longer resides in the facility. Element #2 Residents residing in the facility have the potential to be affected. Resident care plans have been reviewed and updated to reflect current care needs. Element #3 The interdisciplinary team has been re-educated on the Care Planning and Coordination policy. Element #4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s) will conduct weekly audits of care plans to ensure appropriateness. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5 The Administrator is responsible for sustained compliance.
Failure to Provide Adequate Nail Care to a Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care to a dependent resident, resulting in an unkempt appearance and potential for infection. Resident #52, who was severely cognitively impaired and dependent on staff for activities of daily living (ADLs), was observed multiple times with long, dirty fingernails caked with black debris. Despite the resident's expressed preference for clean and trimmed nails, staff did not provide the necessary care. The care plan indicated that Resident #52 required extensive assistance with ADLs, including nail care. Interviews with staff revealed inconsistencies in the provision of nail care, with some CNAs stating it should be done during showers, while others indicated it could be done anytime. An LPN acknowledged the need for nail care but left the resident's room without completing it, citing time constraints. The Director of Nursing expected nails to be clean and trimmed as needed, but there was no documentation of nail care in the resident's records. This lack of consistent care and documentation contributed to the deficiency identified by surveyors.
Plan Of Correction
Element #1: Nail care was provided for Resident #52. Element #2: Residents' dependent for fingernail grooming/hygiene have the potential to be affected. These Residents who are dependent for fingernail grooming/hygiene will be observed for appropriate fingernail grooming/hygiene and any concerns will be addressed at time of observation. Element #3: Certified Nursing Assistants and Licensed Nurses will be re-educated on ADL standards of care. Element #4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Nurse Manager, or designee(s), will randomly audit dependent residents for ADL standards of care. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5: The Administrator is responsible for sustained compliance.
Failure to Administer Diuretic Medication Leads to Hospitalization
Penalty
Summary
The facility failed to provide care in accordance with physician orders and professional standards for Resident #49, who was admitted with diagnoses including congestive heart failure (CHF) and a pacemaker. Upon admission, the resident's diuretic medication, Lasix, was not administered as ordered, leading to significant weight gain and worsening of his medical condition. Despite the resident's attempts to communicate the need for Lasix to the nursing staff, the medication was not consistently provided, resulting in hospitalization for fluid overload and management of skin breakdowns. The Clinical Nurse Supervisor (CNS) confirmed that the resident's diuretic was listed on hospital paperwork but was not administered regularly. The resident's weight was monitored daily due to CHF, but significant weight increases were not reported to the physician, nor were there any adjustments made to the diuretic medication. The resident's weight increased from 94.2 kg at admission to 106 kg by the time of re-hospitalization, with no documentation of provider notification or intervention. Interviews with the Nurse Practitioner (NP) and review of medical records revealed that the facility's Medical Doctor (MD) had noted the need for continued Lasix, but the medication was not consistently administered. The resident's cardiologist identified the lack of Lasix administration during a pacemaker check, leading to the resident's admission to the hospital for diuresis. The facility's failure to administer Lasix as ordered and to address significant weight changes contributed to the resident's deteriorating condition and subsequent hospitalization.
Plan Of Correction
F684 Element #1: Resident #49 physician orders and treatment reviewed and appropriate. Element #2: Residents that reside in the facility have the potential to be affected. Residents have been reviewed for significant change in condition with physician notification. Element #3: Licensed Nurses have been educated on the facility's Change in Condition Notification of Clinician policy. Element #4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s) will conduct weekly audits for residents who have significant change in condition physician communication. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element #5: The Administrator is responsible for sustained compliance.
Failure to Provide Adequate Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide preventative care consistent with professional standards for two residents at risk for pressure injuries. Resident #98, who had a history of pressure injuries and was assessed as being at mild risk, was observed multiple times in a wheelchair with improper positioning and without adequate pressure relief. The resident's blue boots, intended to reduce pressure, were often not securely attached, and the resident was left in the same position for extended periods, leading to a pressure ulcer on the right heel. Despite having a catheter, the resident was not repositioned or provided with adequate pressure relief, and catheter care was not performed during an observed transfer. Resident #65, also assessed as being at mild risk for pressure injuries, was observed spending most of his time in a wheelchair without a pressure-reducing cushion, as required by his care plan. The resident was seated on a hoyer sling instead, which does not provide the necessary pressure relief. Staff interviews confirmed the absence of a pressure-reducing cushion, and the resident was observed in the same position for extended periods without repositioning, increasing the risk of skin breakdown. The report highlights the facility's failure to adhere to care plans and professional standards for pressure ulcer prevention, resulting in inadequate care for residents at risk of pressure injuries. The lack of proper positioning, pressure relief, and adherence to care plans for both residents demonstrates a significant deficiency in the facility's care practices, potentially leading to worsening of existing pressure injuries and the development of new ones.
Plan Of Correction
Element# 1 Braden assessment for resident #65, and #98 have been completed, and interventions implemented based on identified risk areas. Element# 2 Residents at risk for skin breakdown have the potential to be affected. Resident Braden assessment identifying residents at risk have been reviewed as well as appropriate interventions in place. Element# 3 Licensed Nurses and CNAs have been educated on Pressure ulcer prevention including repositioning and support surface implementation. Element# 4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Director of Nursing or designee(s), will conduct weekly observation audits to ensure appropriate skin interventions are in place. The QAPI Committee will review findings monthly and determine ongoing need for audits. Element# 5 The Administrator is responsible for sustained compliance.
Deficiencies in Water Temperature Control and Resident Transfers
Penalty
Summary
The facility was cited for failing to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120°F. During a tour, it was observed that the hot water in the back 100 spa room reached 128°F, despite the presence of a point-of-use mixing valve intended to temper the water to a safe level. Interviews with maintenance staff revealed that the facility did not regularly monitor hot water temperatures to ensure they remained within safe limits, increasing the risk of injury to residents. Additionally, the facility failed to ensure safe chair-to-bed transfers for two residents. One resident, who required substantial assistance for transfers, was observed being transferred by a CNA without the use of a gait belt or assistance from a second staff member, contrary to the resident's care plan. The resident attempted to bear weight on a foot with a pressure wound during the transfer. Another resident, who required a mechanical lift for transfers, was observed being transferred with the hoyer sling improperly attached, risking the resident's safety. Interviews with staff confirmed the improper transfer techniques and the residents' need for specific assistance during transfers.
Plan Of Correction
DPS A Element #1 No residents were mentioned in the citation. Element #2 No residents have been identified at risk. 100 spa rooms are not currently utilized by facility residents. Element #3 Mixing valve in spa room 100 was removed and delimited. Spa room 100 hot water temperature post deliming was under 120 degrees. Facility Maintenance technician has been re-educated on appropriate safe water temperatures in patient care areas. Element #4 Facility Maintenance tech/Designee will complete 5 random weekly temperature checks in resident care areas. Any variances will be addressed at time of observation. Audits to be forwarded to facility QAPI for review and further recommendations. Element #5 The Facility Administrator is responsible for compliance. DPS B Element #1 Resident #98 and #65 have been re-evaluated to determine the amount of assistance needed to transfer safely. Resident care summaries have been updated to reflect current care needs. Element #2 All residents who require assistance with transfers have the potential to be affected by the same deficient practice. Element #3 Licensed nurses and certified nursing assistants have been re-educated on resident care plan/resident care summary regarding the amount of assistance required for a safe transfer and mechanical lift operation. Element #4 Under the direction of the Quality Assurance and Performance Improvement Committee, the Director of Nursing or designee(s) will conduct weekly observation audits of resident transfers including those that use mechanical lifts to assure the correct transfer technique followed. Audits will be forwarded to the Facility QAPI Committee for review and further recommendations. Element #5 The Director of Nursing is responsible for sustained compliance.
Deficiencies in Catheter and Incontinence Care
Penalty
Summary
The facility failed to ensure proper care for two residents with indwelling foley catheters, leading to potential risks of catheter dislodgement, pain, and infection. Resident #98, who was at risk for compromised skin integrity due to impaired mobility and incontinence, was observed without proper catheter securement, causing her pain. The resident had been in her wheelchair for five hours without being toileted, contrary to her care plan, which required toileting every two hours. Additionally, during incontinence care, the catheter was not secured to her leg, and no catheter care was performed, despite the resident's complaints of discomfort. Resident #65, who had a catheter due to bladder outlet obstruction, also did not receive appropriate care. The resident's catheter was not secured with a leg strap as required, and during incontinence care, the CNA did not change gloves after contact with feces, potentially leading to cross-contamination. The CNA also failed to apply barrier cream after cleaning the resident, which is part of standard incontinence care. These deficiencies were observed during staff interviews and direct observations, highlighting lapses in catheter care and infection control practices.
Plan Of Correction
Element #1: For resident #65 and #98, securement devices have been provided per the plan of care. Element #2: Residents residing in the facility receiving assistance with incontinence care and/or have foley catheters have the potential to be affected. Element #3: Licensed nurses and certified nurse assistants will be re-educated to ensure incontinence care and foley catheter care are consistent with professional standards of practice. Element #4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Nurse Manager, or designee(s), will perform randomly weekly audits of dependent residents for appropriate foley catheter care and incontinence care. Weekly audits are to be submitted to the facility QAPI committee for review and further recommendations. Element #5: The Administrator is responsible for sustained compliance.
Failure to Monitor Oxygen Equipment for Resident
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of oxygen delivery equipment for a resident with chronic obstructive pulmonary disorder (COPD). Resident #16, who was severely cognitively impaired, was observed with an empty water bottle connected to her oxygen concentrator, which was still running. The oxygen tech responsible for maintaining the equipment reported that he was unable to perform the scheduled maintenance the previous week due to scheduling issues, resulting in a delay until the following Monday. Interviews with facility staff revealed inconsistencies in the understanding of responsibilities for monitoring the oxygen equipment. The Registered Nurse (RN) and Clinical Nurse Supervisor (CNS) indicated that nurses should monitor and replace empty water bottles as needed, while the Director of Nursing (DON) stated that she did not expect nurses to monitor the equipment, as an external company was responsible for it. This lack of clarity and oversight led to the deficiency in ensuring the oxygen delivery equipment was properly maintained for Resident #16.
Plan Of Correction
Element #1 Residents #16's oxygen delivery equipment water humidifier bottle has been replaced. Element #2 Residents residing in the facility requiring oxygen therapy have the potential to be affected. Their equipment has been inspected and serviced as identified. Element #3 Licensed nurses were re-educated on oxygen equipment usage and appropriate maintenance of equipment. Element #4 Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Nurse Manager, or designee(s), will conduct random weekly audits on residents who require oxygen therapy to ensure proper equipment is available and utilized. Element #5 The Administrator is responsible for sustained compliance.
Failure to Document Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the physician documented a review of pharmacy recommendations and follow-up actions for a resident, leading to potential medication side effects and unnecessary medications. The resident, who was cognitively intact, had several pharmacy recommendations that were not addressed by the physician. These recommendations included changing Lidoderm orders to PRN due to frequent refusals, re-evaluating the need for duplicate therapy with Elderberry Immune Complex and Vitamin C, and discontinuing Peri-Colace due to the use of Linzess. Further recommendations included improving glycemic control by adjusting insulin therapy and considering a gradual dose reduction of Zoloft, as required by federal nursing facility regulations. Despite these recommendations, the physician's response was left blank, with no signature or date, indicating a lack of follow-up on the pharmacy's suggestions. The facility's policy required that pharmacists report any irregularities to the attending physician, medical director, and director of nursing, with actions to be taken within specified timeframes. However, the physician did not review or sign the pharmacy recommendations for the resident, and the facility's nurse liaison acknowledged this oversight during an interview. This lack of documentation and follow-up on pharmacy recommendations resulted in a deficiency in medication management for the resident.
Plan Of Correction
Drug Regimen Review Element #1: Resident #15 has not had any negative outcomes related to observation. Resident #15's Pharmacy Recommendations have been reviewed by the facility provider, and new orders have been placed as deemed appropriate by the provider. Element #2: Residents residing in the facility have the potential to be affected. Element #3: The facility provider that is designated to complete Drug Regimen Review has been re-educated on the facility medication management policy. The medication management policy has been reviewed by the Director of Nursing and Administrator and deemed appropriate. Element #4: The Director of Nursing/designee will complete a random monthly audit on the completion of Drug Regimen Review recommendations. Variances will be corrected at the time of observation. Audits will be forwarded to the facility QAPI committee for further review and recommendations. Element #5: The Administrator is responsible for sustained compliance.
Failure to Provide Required Emergency Lighting in Generator ATS Room
Penalty
Summary
The facility failed to maintain its generator in accordance with NFPA 110 requirements. During an observation, it was found that there was no battery back-up light installed in the electrical room containing the generator Automatic Transfer Switch (ATS), as required by NFPA 110, section 7.3. This deficiency was identified through direct observation and confirmed in an interview with the Maintenance Technician at the time of discovery. The lack of a battery back-up light in the generator ATS room could potentially affect all occupants of the facility, as it would result in no emergency lighting in the event of a generator failure, leaving no lighted access to emergency equipment. The report does not mention any specific residents or staff affected at the time of the deficiency, nor does it provide details about their medical history or condition.
Failure to Maintain Self-Closing Doors in Hazardous Storage Areas
Penalty
Summary
Surveyors observed that the facility failed to ensure proper protection of hazardous areas as required by Life Safety Code (LSC) 19.3.2.1. Specifically, on two separate occasions, it was found that the doors to the Therapy storage closet and the 100 back hall storage closet (used for emergency food and water storage) did not self-close to a positive latch. These deficiencies were identified during direct observation and confirmed through interviews with the Maintenance Technician present at the time. The report notes that these failures could potentially affect 20 occupants in the event of a fire not being contained to the hazardous area. No information about corrective actions or follow-up measures is included in the report, and there are no details provided about specific residents or their medical conditions at the time of the deficiency.
Smoke Barrier Door Failed to Self-Close Due to Improper Alignment
Penalty
Summary
The facility failed to provide smoke barrier doors that were self-closing or automatic-closing as required by Life Safety Code (LSC) 19.3.7.8 and Chapter 7. During an observation, it was found that the north cross-corridor door leaf at the 100 front hall near room 121 was not plumb, causing it to bind on the floor. This condition prevented the door from releasing upon activation of the fire alarm and from closing sufficiently to maintain the minimum clearance necessary for proper operation in accordance with LSC 7.2.1.8.2. These findings were confirmed during an interview with the Maintenance Technician at the time of discovery.
Inadequate Supervision Leads to Resident's Choking Death
Penalty
Summary
The facility failed to ensure the safety and provide adequate supervision for a resident with a history of dysphagia and choking incidents, resulting in the resident choking on food and subsequently dying. The resident, who had a history of dementia, oropharyngeal dysphagia, and larynx cancer, was on a specialized diet due to his condition. Despite being educated on the risks of not adhering to the recommended diet, the resident chose to eat foods that were not suitable for his condition. The facility did not implement sufficient interventions to ensure his safety while eating, especially when he chose to eat in his room. The resident's care plan indicated that he should eat in communal dining areas for increased supervision, but this was not consistently enforced or documented in the Resident Care Summary. During a COVID-19 outbreak, the main dining room was closed, and the resident was allowed to eat in his room without adequate supervision. Staff members were not fully aware of the resident's need for increased supervision during meals, and there were no additional safety measures in place when he ate alone in his room. On the day of the incident, the resident was found unresponsive in his room after choking on a piece of steak. Despite efforts to resuscitate him, he was declared dead, and the cause of death was determined to be choking. The facility's lack of consistent supervision and failure to implement necessary safety interventions contributed to the resident's death.
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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