Froh Community Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Sturgis, Michigan.
- Location
- 307 N Franks Avenue, Sturgis, Michigan 49091
- CMS Provider Number
- 235345
- Inspections on file
- 20
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Froh Community Home during CMS and state inspections, most recent first.
Surveyors observed that food items in the kitchen and kitchenette, including peaches, yogurt, milk, and potato chips, were not properly labeled, dated, or discarded according to FDA Food Code requirements. This failure created the potential for foodborne illness among residents consuming food from these areas.
Two residents with histories of trauma and cognitive impairment did not receive required trauma care assessments or individualized care plans. Staff confirmed that trauma assessments were not completed upon admission, and care plans addressing trauma needs were either delayed or missing, despite facility policy requiring trauma screening within 14 days.
Two residents requiring CPAP therapy were found with their respiratory equipment improperly cleaned and stored, with masks left exposed to dust and debris on personal items at the bedside. Staff interviews revealed confusion about cleaning responsibilities, and daily cleaning procedures outlined in physician orders and facility policy were not consistently followed or documented. One resident's care plan also lacked a comprehensive treatment plan for CPAP use.
Staff did not use required PPE, including gowns and gloves, during high-contact care activities for a resident with an MDRO who was under enhanced barrier precautions. Despite care plan orders and facility policy, a CNA was observed making the resident's bed without PPE, and there was confusion among staff regarding the need for precautions and proper signage.
A fire alarm pull box at the activities west exit door was found to be obstructed and not immediately accessible during an observation, in violation of NFPA 70 and NFPA 72 requirements. The Maintenance Director confirmed the finding at the time of the survey.
Surveyors observed missing ceiling tiles in the drop ceiling grid of the wheelchair storage room near the nurse station, which was confirmed by the Maintenance Director. This failure to maintain the ceiling structure could impact the sprinkler system's heat collection process, resulting in noncompliance with NFPA 25 requirements.
Several corridor doors, including those to resident rooms, were unable to close and positively latch due to PPE hangers mounted on top of the doors, preventing them from resisting the passage of smoke as required. This issue was confirmed by the Maintenance Director during surveyor observation and could potentially affect multiple occupants within the smoke compartment.
Surveyors found a hydrocollator machine used for hot pads placed directly on a towel in the therapy area, with the device hot enough to cause burns upon touch. The machine was not installed to prevent ignition of combustibles, as required, and this was confirmed by the Maintenance Director. This deficiency could potentially affect eight occupants in the therapy area.
The facility failed to hold Quality Assessment and Assurance (QAA) meetings at least quarterly as required. The DON could not provide documentation for QAA meetings from September 2023 to January 2024, and the ADON confirmed a canceled meeting in November 2023 that was not rescheduled.
The facility failed to ensure proper infection control protocols, including Enhanced Barrier Precautions (EBP) and hand hygiene, for several residents with wounds, catheters, and infections. Staff did not don PPE, clean equipment, or perform hand hygiene, increasing the risk of infection spread and cross-contamination.
The facility failed to offer the updated pneumococcal vaccines to four residents, resulting in a delay in their opportunity to receive or decline the vaccination. The Infection Preventionist was unaware of the changes to the immunization requirements, leading to the oversight.
The facility failed to preserve resident dignity during meal service, leaving three residents who required assistance with eating to wait up to 40 minutes while others around them were served and consumed their meals. Staff interviews confirmed that the dining room service process led to these residents being served last, causing them to watch their tablemates eat while they waited.
The facility failed to provide a written notice of transfer for a resident hospitalized due to a myocardial infarction, resulting in the potential for residents and/or their representatives being uninformed of the reason for transfer and their rights. Staff interviews revealed a lack of awareness and adherence to the policy requiring a transfer notice.
The facility failed to ensure that a licensed pharmacist completed monthly medication regimen reviews for a resident with vascular dementia, insomnia, and chronic pain. Despite the care plan indicating the need for pharmacy consultant reviews, no reviews were found in the resident's medical record for several months, as confirmed by the Director of Nursing.
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use. The resident was prescribed lorazepam 0.5 mg PRN for anxiety with no end date, contrary to the requirement that PRN psychotropic medications be limited to 14 days. No gradual dose reductions (GDRs) were attempted, and the lack of auditing led to incomplete monitoring of the medication's use and potential adverse reactions.
Failure to Label, Date, and Discard Food Items per FDA Food Code
Penalty
Summary
The facility failed to ensure proper labeling, dating, and discarding of food items in both the main kitchen and a kitchenette, as observed during multiple tours. In the walk-in refrigerator, a large plastic container of peaches was found without any label or date. Additionally, a plastic container of yogurt and an open half-gallon jug of 2% milk were found with open dates of 5/17 and expiration dates of 5/19, while another open half-gallon jug of 2% milk lacked any label or date. In the kitchenette by Maple and Oak Halls, an open bag of potato chips was observed to be unsealed and without a label or date. These findings were confirmed during observations with the Certified Dietary Manager, Chef Manager, and Food Service Regional Director of Operations. The lack of proper labeling, dating, and discarding of food items is not in accordance with the 2022 FDA Food Code, which requires ready-to-eat, time/temperature control for safety foods to be clearly marked with the date by which they must be consumed, sold, or discarded. The failure to follow these standards created the potential for foodborne illness among all residents consuming food from the kitchen.
Failure to Complete Trauma Assessments and Care Plans for Residents with Trauma Histories
Penalty
Summary
The facility failed to complete trauma care assessments and develop corresponding care plans for two residents with known histories of trauma. Both residents were identified on the facility matrix as having PTSD or trauma, and their Minimum Data Set (MDS) assessments indicated cognitive impairment, anxiety, and depression. For one resident, the care plan addressing psychosocial well-being was created several months after admission, and no trauma assessment was found in the medical record. The social services staff confirmed that no trauma assessment had been completed for this resident, despite being aware of her trauma history. For the second resident, the MDS showed she was not cognitively intact and had diagnoses of anxiety and depression. The resident's guardian reported that trauma was not indicated in the facility's referral, and the social services staff acknowledged that no formal trauma assessment was completed upon admission. The Director of Nursing confirmed that trauma assessments should be completed within 14 days of admission and that neither resident had a trauma assessment or a starting point for treatment documented in their records. Facility policy requires trauma screening within 14 days of admission, but this was not followed for these residents.
Failure to Ensure Proper Cleaning and Storage of CPAP Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and storage of respiratory equipment for two residents who required CPAP therapy. One resident, who was cognitively intact and had a history of heart failure and pneumonia, was observed multiple times with a CPAP mask left unprotected on personal items at the bedside, exposed to dust and debris. The resident expressed concern about the cleanliness of the mask and stated that staff assisted with mask removal but was unsure if it was cleaned as required. Staff interviews revealed confusion about cleaning responsibilities, and review of physician orders and care plans confirmed that daily cleaning was required but not consistently performed or documented. Another resident, who was cognitively impaired with diagnoses including dementia, partial paralysis, and Parkinson's disease, was also observed with a CPAP mask covered by a fabric but still left on personal items and exposed to dust and debris. The mask was sometimes covered with a stuffed animal on top. Staff interviews and policy review indicated that the mask should be cleaned daily and protected, with fabric coverings switched out daily due to the resident's skin sensitivity. However, observations showed that these procedures were not consistently followed, and the resident's care plan did not include a comprehensive treatment plan for CPAP use.
Failure to Use PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use required personal protective equipment (PPE), specifically gowns and gloves, during high-contact care activities for a resident who was under enhanced barrier precautions (EBP) due to a multidrug-resistant organism (MDRO). The resident, a male with severe cognitive impairment and multiple diagnoses including candidal sepsis and diverticulitis with perforation, had physician orders and a care plan in place requiring EBP for high-contact activities such as dressing, bathing, transferring, and changing linens. On one occasion, a CNA was observed making the resident's bed without wearing any PPE, despite the care plan and facility policy specifying that gown and gloves should be used during such activities. Further review revealed inconsistencies in the availability and signage of PPE for the resident. Initially, no signage or PPE was present in or outside the resident's room, but later signage and a PPE supply bin were observed. The CNA involved stated that PPE was only necessary for residents in isolation and believed the resident was no longer under such precautions, indicating a lack of understanding of EBP requirements. The Assistant Director of Nursing/Infection Preventionist confirmed that the resident was still under EBP and that staff were expected to use PPE during high-contact care, including linen changes.
Obstructed Fire Alarm Pull Box at Activities West Exit
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program as required by NFPA 70 and NFPA 72. During an observation, it was found that the fire alarm pull box located at the activities west exit door was obstructed and could not be immediately accessed. This issue was confirmed through an interview with the facility Maintenance Director at the time of observation. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
Obstructions in front of the Activities fire alarm pull box have been removed. All other pull stations have been inspected and none are obstructed. All pull-station areas will be inspected on a weekly basis by the maintenance department to make sure there are no obstructions preventing access to the pull stations. All Department Managers and Maintenance staff will be inserviced on keeping pull stations free from obstructions. The Maintenance Director will monitor compliance by completing rounds weekly, observing for obstructed pull stations.
Sprinkler System Maintenance Deficiency Due to Missing Ceiling Tiles
Penalty
Summary
The facility failed to maintain and test the automatic sprinkler system in accordance with NFPA 25 requirements. During an observation, surveyors found missing ceiling tiles in the drop ceiling grid within the wheelchair storage room near the nurse station. This deficiency was confirmed through an interview with the Maintenance Director at the time of observation. The absence of ceiling tiles could interfere with the sprinkler system's heat collection process, as required by NFPA 25, 5.2.1. No information about specific residents, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
The ceiling tiles in the wheelchair storage room have been installed. All other areas of the building have been inspected, and no other ceiling tiles are missing. Ceiling tiles will be inspected on a weekly basis by the maintenance department and documented in the preventative maintenance log. The Maintenance Director will monitor compliance by completing rounds weekly, observing for missing ceiling tiles.
Corridor Doors Blocked by PPE Hangers Preventing Smoke Resistance
Penalty
Summary
The facility failed to ensure that corridor doors protecting corridor openings were able to resist the passage of smoke as required by NFPA 19.3.6.3. During observations, it was found that several resident room doors, specifically room #3 in cottonwood hall and rooms #44 and #4 in maple hall, did not close and positively latch. The deficiency was directly caused by personal protective equipment (PPE) hangers that were mounted on the top of these doors, which physically prevented the doors from closing and latching as required. These findings were confirmed during interviews with the facility Maintenance Director at the time of observation. The report notes that this issue could potentially affect 24 occupants within the smoke compartment if the doors fail to prevent the passage of smoke during a fire. The deficiency was identified through direct observation and interview, with no mention of corrective actions or follow-up steps included in the report.
Plan Of Correction
Maintenance removed all over the door hangers and mounted PPE holders with a different method so as not to impede door from having a positive latch. All other doors have been inspected to ensure that no obstructions keep the doors from latching. The maintenance staff will check doors weekly and document checks in the preventative maintenance log. The Maintenance Director will monitor compliance by conducting rounds weekly, observing for door latching issues.
Improper Placement of Hydrocollator Machine Creates Fire Hazard
Penalty
Summary
A deficiency was identified when surveyors observed a hydrocollator machine, used for hot pads, placed on top of a towel in the therapy area. The machine was found to be hot enough to cause a heat burn upon contact, and it was not installed in a manner that would prevent combustible materials from being ignited, as required by code 19.5.2.2. The observation was confirmed by the facility Maintenance Director at the time of the survey. This situation could potentially affect eight occupants within the therapy area if ordinary combustibles come into contact with the heat source.
Plan Of Correction
Hydrocollator was removed from the shelf and towel location and installed on a metal shelf. All other heat producing equipment has been reviewed to ensure that combustible items are not touching them. Department Managers and Maintenance staff will be inserviced on the safe use of heat producing equipment. The Maintenance Director will monitor compliance by conducting rounds weekly, observing for combustible materials are keep away from heat producing equipment.
Failure to Hold Quarterly QAA Meetings
Penalty
Summary
The facility failed to ensure that Quality Assessment and Assurance (QAA) meetings were held at least quarterly, as required. During an interview, the Director of Nursing (DON) presented a QAA binder with meeting sign-in sheets and notes dated February, March, and April 2024, indicating that the facility had changed QAA meetings from quarterly to monthly starting in February 2024. However, the DON was unable to locate the quarterly sign-in sheets from September 2023 to January 2024 to confirm whether QAA meetings were held during that period and who attended. Additionally, the Assistant Director of Nursing (ADON) mentioned that a QAA meeting scheduled for November 2023 was canceled and was unsure if it was rescheduled. The facility's QAPI policy requires QAA meetings to be held at least quarterly, but there was no documentation to verify compliance with this requirement for the specified period.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control protocols and practices, including Enhanced Barrier Precautions (EBP) and transmission-based precautions, for several residents. For instance, Resident #31, who had a suprapubic catheter, did not have any EBP signage or personal protective equipment (PPE) available for staff. Similarly, Resident #50, who had a Foley catheter, also lacked EBP signage and PPE. Resident #27, with a pressure ulcer and a Foley catheter, did not have EBP signage, and staff did not don PPE before performing wound care. Additionally, Resident #261, who had a urinary tract infection with a multidrug-resistant organism, did not have contact precautions in place, and staff entered the room without PPE. Resident #262, with multiple wounds and cellulitis, and Resident #5, with pressure ulcers, also lacked EBP signage and PPE in their rooms. The Infection Preventionist (IFP) was unaware of the updated guidance for implementing EBP for residents with wounds, pressure ulcers, and indwelling devices. The facility also failed to ensure adequate hand hygiene and hygienic wound care. For example, CNA F did not clean the Hoyer lift after transferring Resident #5, and CNA E did not perform hand hygiene after handling soiled linen and taking a drink from a personal beverage cup in the spa room. Additionally, Wound Nurse Z did not turn off a pedestal fan blowing air directly at Resident #5's feet during a dressing change, which disturbed the dressing supplies. These deficiencies resulted in an increased potential for the spread of infection, bacterial harborage, cross-contamination, and disease transmission among residents. The facility's failure to implement proper infection control measures, including EBP and hand hygiene, compromised the safety and well-being of the residents.
Failure to Offer Updated Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to four residents, resulting in a delay in the residents being given the opportunity to receive or decline the vaccination. Resident #26, a female with diagnoses including heart failure, diabetes, and dementia, had previously received PCV13 and PPSV23 but was not offered the updated PCV15 or PCV20 vaccine. The Infection Preventionist (IFP) was unaware of the changes to the immunization requirements. Similarly, Resident #50, a male with conditions such as acute kidney failure and diabetes, had also received PCV13 and PPSV23 but was not offered the updated vaccines. The IFP confirmed that this resident should have been offered the PCV15 or PCV20 vaccine as well. Resident #38, a female with dementia and Parkinson's disease, had received a pneumococcal vaccine at an unknown outside setting and should have been offered the updated vaccines according to the IFP. Resident #24, a female with diagnoses including diabetes and leukemia, had also received a vaccine from an outside provider, but this was not documented in the medical record. The IFP reported that this resident should have been offered the PCV15 or PCV20 vaccine and then PPSV23 one year later. The CDC guidelines indicate that adults who have previously received PCV13 and PPSV23 should receive a dose of PCV20 at least five years after the last pneumococcal vaccine dose, or if their vaccination history is unknown, they should receive one dose of PCV15 or PCV20.
Failure to Preserve Resident Dignity During Meal Service
Penalty
Summary
The facility failed to preserve resident dignity during meal service in the dining room for three residents who required assistance with eating. Observations revealed that these residents were seated with drinks and desserts in front of them but were unable to consume them without assistance. They were left waiting for up to 40 minutes while other residents around them were served and consumed their meals. This resulted in the residents being unable to eat or drink independently for an extended period, which could lead to feelings of embarrassment and shame. Interviews with staff members indicated that the dining room service process involved serving hall trays first, followed by residents needing some assistance, then independent residents, and finally those requiring full assistance. This process led to the residents who needed direct assistance being served last, causing them to watch their tablemates eat while they waited. The Director of Nursing and Assistant Director of Nursing acknowledged that residents should not be left waiting to be served while others at their table are eating, indicating a recognition of the issue but no immediate corrective action was mentioned in the report.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written notice of transfer for a resident who was hospitalized, resulting in the potential for residents and/or their representatives being uninformed of the reason for transfer and their rights. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognition, was discharged to the hospital due to a myocardial infarction and returned to the facility after a week. During an interview, the resident could not recall receiving a written transfer notice. A review of the resident's chart and the December 2023 Transfer Log confirmed that no written notice of transfer was provided, which should have included specific information such as the reason for transfer, effective date, location, appeal rights, and contact information for relevant advocacy agencies. Interviews with facility staff, including a Registered Nurse, the Director of Nursing, and a Financial Assistant, revealed a lack of awareness and adherence to the policy requiring a transfer notice. The Director of Nursing presented paperwork sent with residents to the hospital, which did not include a transfer/discharge notice. The Financial Assistant admitted that transfer/discharge notices had not been given to residents or their responsible parties for a long time, especially if the resident wanted to go to the hospital. The facility's Discharge Planning Policy indicated that the Business Office should provide notice of transfer or discharge within 24 hours or as soon as practicable in emergency situations, but this was not followed in the case of the resident in question.
Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly medication regimen review for one resident reviewed for unnecessary medication use. Resident #28, who had diagnoses including vascular dementia, insomnia, and chronic pain, was mildly cognitively impaired with a BIMS score of 11 out of 15. The resident had a physician's order for lorazepam to be taken as needed up to four times a day. Despite the care plan indicating the need for pharmacy consultant reviews, no monthly medication regimen reviews were found in the resident's medical record from January 2024 to April 2024. This was confirmed by the Director of Nursing, who reported that no reviews had been completed during this period.
Failure to Limit PRN Psychotropic Medication and Implement GDRs
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medication use, specifically in the case of Resident #28. Resident #28, who had diagnoses including vascular dementia, insomnia, and chronic pain, was prescribed lorazepam 0.5 mg PRN for anxiety with no end date. The care plan indicated that the resident should be prescribed the lowest effective dose and that the resident's mood and response to the medication should be observed. However, the PRN order for lorazepam was not limited to 14 days as required for psychotropic medications, and no gradual dose reductions (GDRs) were attempted for the resident's PRN use of lorazepam. Interviews with the RN and DON confirmed that the PRN order was open-ended and that no GDRs had been completed for Resident #28. The Director of Nursing (DON) reported that new medication orders were reviewed by the clinical team in daily meetings and all medications were reviewed weekly, but no audits were completed on original orders. This lack of auditing and failure to implement GDRs or limit the PRN order to 14 days resulted in incomplete monitoring of the use, potential adverse reactions, and dosage adjustments of the psychotropic medication for Resident #28.
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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