Greenfield Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Royal Oak, Michigan.
- Location
- 3030 Greenfield Ave, Royal Oak, Michigan 48073
- CMS Provider Number
- 235433
- Inspections on file
- 33
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Greenfield Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with anxiety disorder and diabetes, who was cognitively intact, reported that a staff member cussed at them during a bed transfer and documented this on a concern form submitted to the Administrator. The Administrator conducted an internal review, obtained witness statements from two CNAs the following day describing the resident cussing at staff, and concluded the allegation was not substantiated. The Administrator did not report the allegation to the State Agency, instead treating it as a concern due to the resident’s history of making allegations and the presence of another staff member, despite facility policy requiring all abuse allegations to be reported to the State Survey Agency within two hours.
Surveyors found that the facility failed to provide a varied, resident-centered activity program, relying heavily on repetitive schedules, TV viewing, and faith-based activities with no offerings later in the day. The posted activity calendar was outdated and partially updated, and a scheduled craft activity did not occur. Multiple residents reported boredom, lack of non-spiritual activities on Sundays, canceled or unfulfilled events such as karaoke, and no community outings despite interest. One resident who wished to participate in cards, current events, nail care, and getting out of bed had no documented activities for a month aside from a few room visits. Staff oversight was limited, with the administrator acknowledging the program did not engage residents and the corporate activity coordinator confirming inconsistent implementation and awareness of days with no activities.
A resident with severe cognitive impairment and multiple medical conditions was admitted with skin impairments on the right lower leg, heel, and top of the foot. On admission, staff documented the presence of these skin issues but did not specify the wound type, provide measurements, or describe characteristics such as color or drainage, contrary to the facility’s Skin and Wound Guidelines. Wound care treatments for these areas were not ordered until three days after admission, and the DON later acknowledged that a thorough skin assessment and treatment orders should have been completed at the time of admission.
A nurse with limited experience administered 100 units of short-acting insulin instead of the prescribed 3 units to a resident with diabetes and recent hypoglycemia. The error occurred due to misreading the medication order and failing to verify the correct dose, resulting in the resident experiencing severe hypoglycemia and requiring ICU hospitalization.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Surveyors found that the Activity Director did not meet the minimum qualifications required for the position, as there was no license, certification, or sufficient relevant experience documented. The Administrator confirmed the lack of required credentials and experience, and the facility's job description outlined qualifications that were not met.
The facility did not maintain adequate nursing staff to meet resident needs, with multiple staff and resident interviews confirming frequent short-staffing, especially on weekends. Staff reported modifying care routines due to low staffing, and residents described delays in care and missed showers. Facility records and submitted data supported these findings.
The facility did not revise its facility-wide assessment and staffing plan after reopening and utilizing the 2 South unit, resulting in the assessment inaccurately reflecting that the unit was not staffed. The most recent assessment lacked documentation of the change, and the Administrator confirmed the oversight.
A resident with an above-the-knee amputation and a contracted left hand was repeatedly documented in MDS assessments as having no impairment in upper or lower extremities, despite direct observation and occupational therapy evaluation confirming significant limitations. MDS assessments were completed offsite and signed by an RN not regularly present, with input from a new MDS nurse in training, leading to inaccurate documentation of the resident's condition.
Two residents were affected by window air conditioning units that were not properly sealed, leaving gaps that allowed insects to enter their room. During inspections, insects were observed on a pillowcase and window sill, and the Maintenance Director confirmed the improper sealing of the units, which did not meet the facility's standards for a safe and clean environment.
A resident with severe cognitive impairment was found with facial bruising and swelling by a family member, and the cause of the injury could not be determined. Despite facility policy requiring immediate reporting of injuries of unknown source, the incident was not reported to the State Agency, as staff relied on a delayed and questionable statement from the resident. This failure to report constituted a deficiency.
A resident with severe cognitive impairment and multiple medical conditions was admitted, readmitted, and later began hospice care. After a significant change MDS assessment, the facility did not conduct a required care planning review involving the resident, legal representative, interdisciplinary team, or hospice staff. Staff interviews confirmed the care conference was not completed as required by facility policy.
A resident requiring a two-person assist and mechanical lift did not receive showers after admission due to the facility lacking appropriate equipment, resulting in only bed baths being provided. Staff interviews indicated uncertainty about available resources, and there was no documentation of shower refusals or care plan instructions addressing the resident's bathing needs, despite facility policy requiring such care.
A resident with severe cognitive impairment developed a Stage 3 pressure ulcer after staff failed to promptly document, notify the physician, and initiate treatment following the initial identification of a wound. The delay in obtaining treatment orders and implementing interventions was acknowledged by the acting DON as contributing to the progression of the ulcer.
A resident with COPD and other respiratory conditions was observed with a nasal cannula, but the oxygen concentrator was not running and set to 0 liters, despite a physician's order for continuous 2L oxygen. Staff confirmed the resident should have been receiving oxygen, and the issue was only corrected after surveyor intervention.
A resident with severe cognitive impairment and psychiatric diagnoses did not receive timely administration of prescribed quetiapine due to delays in medication acquisition and lack of documentation. MARs showed conflicting entries regarding medication availability and administration, and staff could not confirm if the medication was given or pulled from back-up supply. Review found no evidence the medication was available or administered as ordered.
A resident with multiple chronic conditions and a newly identified pressure ulcer did not have Enhanced Barrier Precautions (EBP) implemented as required. There was no signage or PPE cart outside the room, and staff were unaware that EBP had not been initiated, despite facility policy mandating these precautions for residents with wounds.
A resident who was dependent on staff for most ADLs and had intact cognition developed a scalp wound that was not identified or documented in a timely manner. Despite expectations for weekly skin assessments and daily CNA care, the wound was only discovered after the resident reported pain and drainage, leading to a hospital transfer where cellulitis and infection were confirmed. Facility leadership acknowledged the wound should have been identified earlier and that required documentation was missing.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Staff failed to ensure call lights were within reach for five residents with significant cognitive and physical impairments, leaving call lights on the floor or out of reach even after care was provided. Nursing staff and the DON confirmed that maintaining call light accessibility is a shared responsibility, and care plans specified the need for call lights to be accessible.
A resident experienced ongoing issues with a leaking bathroom ceiling, leading to frequent clothing changes and frustration. The bathroom had a foul odor, flying insects, and visible water damage. The Maintenance Director and DON were only recently informed, despite the resident's report of the problem persisting for a week. The resident, with intact cognition and multiple diagnoses, was tearful when discussing the issue.
A resident with Hypothyroidism and Osteoarthritis did not receive their prescribed Synthroid and Tylenol due to a failure in medication administration processes. The resident, who has intact cognition, reported frequent issues with missed medications. Nurse D confirmed the oversight, and the DON acknowledged the process issue but stated it was not an excuse for the failure.
A resident with rheumatoid arthritis and foot drop did not receive recommended care from an orthopedic specialist, as the facility failed to implement orders for a brace and compression socks. The resident expressed concerns about the lack of follow-through, and the Director of Nursing confirmed that no justification was documented for not following the specialist's recommendations.
A resident experienced significant distress due to a delay in receiving prescribed anti-anxiety medication, Ativan, at a nursing facility. Despite the medication order being confirmed, an LPN failed to administer it for four hours, prioritizing a break instead. This neglect led to a physical altercation between the resident and the LPN, who also exhibited unprofessional behavior by threatening to involve her husband and using inappropriate language.
A resident with severe cognitive impairment was allegedly involved in an inappropriate incident with a visitor, which was observed by a CNA. Despite the facility's policy requiring immediate reporting of abuse allegations, the incident was not reported to the Administrator or State Agency in a timely manner, as the CNAs involved failed to follow the proper reporting procedures.
The facility failed to maintain an effective pest control program, resulting in the presence of gnats, house flies, and sewer flies throughout the building. A missing door seal allowed insects to enter, and the Maintenance Director was unaware of this issue. Pest control documentation did not address the problem, and the DON confirmed the need for better communication and education on reporting pest concerns.
The facility failed to maintain a safe, clean, and homelike environment, affecting multiple residents. Observations revealed issues such as loose wires, water damage, mold-like substances, and unclean conditions in resident areas. Staff interviews indicated a lack of awareness and communication regarding these concerns, with no reports in the facility's work order system. The facility's policy emphasized maintaining a clean environment, but staff failed to report or address the deficiencies.
A resident with a history of heart attack and respiratory issues was found with an unsecured portable oxygen tank next to their bed, posing a potential hazard. The tank was empty, and the resident was unsure of how long it had been there. A nurse confirmed the oversight, which was against the facility's policy requiring oxygen cylinders to be secured.
A resident's medication, carvedilol, was improperly stored at the bedside, contrary to facility policy. The resident, with a history of multiple health issues and deemed incompetent to make medical decisions, had their medication left unsecured. Nurse 'C' confirmed the pill was held earlier due to low blood pressure, but it was found on the bedside table instead of being secured.
A resident with intact cognition and multiple diagnoses fell from bed while being assisted by staff due to inadequate supervision and a hazardous environment. The staff member assisting the resident was incorrectly positioned, and the resident attempted to grab a broken chair for support, leading to the fall. The facility failed to follow its fall management guidelines and did not have necessary assistive devices in place prior to the incident.
The facility failed to protect three residents from physical and verbal abuse by staff and other residents. One resident was physically and verbally abused by an LPN, another was assaulted by their aggressive roommate, and a third experienced antisemitic verbal abuse from their roommate. The facility did not document or report these incidents in a timely manner.
The facility failed to report actual and alleged physical and verbal abuse to the Abuse Coordinator, law enforcement, and/or the State Agency within the required time frame for six residents, resulting in significant delays in investigating incidents and continued employment of the alleged perpetrators.
The facility failed to investigate witnessed and alleged resident-to-resident physical and verbal abuse and did not thoroughly investigate a bruised eye of unknown origin for five residents. Incidents included physical assault, verbal abuse with antisemitic slurs, and unexplained eye trauma. The facility's Administrator was unaware of some incidents, and investigations were incomplete or not conducted.
The facility failed to follow a resident's DPOA wishes for their code status, leading to a discrepancy between a DNR order and a conflicting FULL CODE document signed by another family member. The resident, who was deemed incompetent, had their correct DNR status confirmed by the DPOA after the issue was discovered.
A resident admitted for skilled rehabilitation and nursing services did not receive a Notice of Medicare Non-Coverage (NOMNC) due to a transition period within the social work department. This failure resulted in the resident and/or their representative not being informed of their right to appeal, potentially causing emotional and financial hardships.
The facility failed to ensure accurate MDS assessments for a resident with Wernicke's encephalopathy, who frequently refused care, medications, and services. Despite these refusals, the resident's MDS assessments inaccurately documented no behaviors or rejection of care. The MDS Coordinator confirmed the assessments should have been accurate.
The facility failed to complete required PASARR screenings for two residents with serious mental illness and intellectual disabilities. Despite documented diagnoses and treatments, necessary Level I and Level II screenings were not conducted, and MDS assessments inaccurately reflected their conditions.
The facility failed to consistently monitor the blood pressure of a resident with hypertension, leading to an emergency hospital transfer. The resident was found unresponsive with a blood pressure of 189/93 mmHg, and hospital records indicated an increased blood pressure of 196/120 mmHg upon admission. The last documented blood pressure reading was ten days prior, despite the care plan's instructions to obtain vital signs and notify the physician as needed.
The facility failed to follow physician orders for assistive devices for two residents, leading to potential decline in range of motion and worsening of contractures. Observations showed that prescribed braces and palm protectors were not applied, and care plans were not properly updated.
The facility failed to provide appropriate supervision and positioning during showers and therapy for two cognitively impaired residents, resulting in significant injuries. One resident fell in the shower and sustained compression fractures, while another fell during a physical therapy session, hitting their head and flipping their wheelchair.
The facility failed to implement a psychiatrist's recommendations for a resident with multiple mental health disorders, including adjustments to medications and a room change. Despite the psychiatrist's orders, the necessary changes were not made in a timely manner, and staff interviews confirmed a lack of follow-up to ensure these recommendations were implemented.
The facility failed to evaluate the competency and obtain guardianship for a resident with severely impaired cognition who did not have a resident representative. The resident was observed in a disheveled state and appeared confused. The Director of Social Services confirmed that a competency evaluation was required but had not been conducted, and the facility's policy on advance directives had not been implemented for this resident.
The facility failed to accurately document and reconcile two controlled medications for a resident during a random surveillance of the narcotic drawer. The LPN admitted that the medications were administered but not signed off in the narcotic binder, which was confirmed by the ADON as a violation of the facility's medication administration policy.
The facility failed to schedule follow-up dental services for a resident with multiple fractured teeth and moderate cognitive impairment. Despite previous dental consults and concerns expressed by the resident's legal guardian, no further attempts were made to obtain a dental appointment after 2/24/23. Observations revealed the resident was experiencing discomfort and bleeding from their teeth, and interviews confirmed a lack of follow-up documentation.
A resident with multiple diagnoses experienced a significant delay in receiving physical therapy services despite multiple requests and hospice documentation. Facility staff were aware of the need but failed to coordinate and follow up in a timely manner, leading to the resident's prolonged wait and frustration.
The facility failed to inform a resident's legal guardian of a room change, medical recommendations following a neurology appointment, and the offer of an influenza vaccine. The resident had severe cognitive impairment and a court-appointed guardian, but there was no documentation that the guardian was notified of these significant events, leading to a complaint and citation.
The facility failed to appropriately store resident property, leading to potential loss or theft. An LPN was found storing cash and a cell phone belonging to two residents in a medication cart. The ADON confirmed that such items should be stored in the business office, but the LPN placed the items back into the cart after the observation. The facility's policy on personal belonging storage was not provided by the end of the survey.
The facility failed to implement preventative interventions and timely assess and identify the formation of pressure ulcers for a resident, resulting in the resident acquiring one Stage 2 and two Stage 3 pressure ulcers. The resident, with severe cognitive impairment and dependent on staff for all ADLs, developed these ulcers despite existing interventions. The facility's staff confirmed the presence of the ulcers, and the Acting DON acknowledged that staff should identify skin concerns before they progress to Stage 3.
The facility failed to ensure vaccine consent/declination was signed by a resident's legal guardian and did not accurately track and administer pneumococcal vaccinations for three residents. The ADON confirmed that any consent should always be signed or declined by the legal guardian and had no explanation for why the pneumococcal vaccines had not been administered as recommended by CDC guidelines.
A resident with severe cognitive impairment suffered a fractured finger after a male staff member allegedly pressed on his hand. Despite consistent statements from the resident and reports of the staff member's aggressive behavior, the facility's investigation was inconclusive, and the staff member was only suspended pending further investigation.
Failure to Report Resident’s Verbal Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal abuse by staff to the State Agency within the required timeframe. A resident (R801) with diagnoses including anxiety disorder and diabetes, and assessed as having intact cognition on a recent MDS, reported on 4/23/26 via a Concern Form that a staff member had cussed at them during a bed transfer. The Administrator documented that interviews were held, the allegation was not substantiated, and that a one-to-one discussion occurred with the resident, who remained dissatisfied with the outcome. The Administrator signed the Concern Form the same day and noted that the resident did not accept the outcome of the investigation. Witness statements from CNA A and CNA B were obtained the following day, 4/24/26. CNA A reported that CNA B assisted with transferring the resident from bed and that the resident yelled insulting comments at CNA B. CNA B reported that two days prior, while delivering a dinner tray, the resident began cussing and stating that CNA B should do what the resident asked, and that during the subsequent transfer with CNA A, the resident again cussed and threatened to get CNA B fired. In an interview on 4/29/26, the Administrator, who served as the Abuse Coordinator, stated that their protocol was to conduct a preliminary investigation and decide within two hours whether to report an allegation to the State Agency. The Administrator acknowledged that the allegation from R801 was not reported because it was treated as a concern rather than an abuse allegation, based on the presence of another staff member in the room and the resident’s history of making allegations, despite facility policy requiring all abuse allegations to be reported to the State Survey Agency immediately, but not later than two hours after the allegation is made.
Failure to Provide Varied, Resident-Centered Activity Program
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain a facility-wide activity and recreation program that reflected varied interests and resident preferences, and that accounted for residents’ cognitive and physical abilities. Surveyors observed that the large activity calendar posted outside the dining room was outdated, still showing February activities well into March, and later only partially updated through early March. During multiple observations in the dining room, where most activities were supposed to occur, residents were largely seated in front of a television, with several sleeping and no staff engagement or evidence of structured activities taking place, including a scheduled Shamrock Craft that did not occur. Interviews with residents revealed dissatisfaction and boredom with the activity program. One resident reported that on certain days the only activity was watching whatever the activity aide put on the TV and that there had been no outings away from the building for years, despite resident interest in a shopping trip. Another resident stated that Sundays had only spiritual activities and sometimes no activities at all, and that a previously planned karaoke event never happened. During a resident council meeting, residents complained that when they were supposed to be watching a movie, someone would turn on loud music or staff would turn the movie off before it finished. The facility had no resident council minutes for the prior three months, having self-identified concerns with resident council. Record review and staff interviews further demonstrated inadequate individualization and follow-through. One resident reported not participating in activities because staff never came to ask them, but said they would participate if asked and assisted, expressing interest in cards, current events, nail care, and getting out of bed. That resident’s electronic activity log for a 30‑day period showed no documented activities, and a paper log for the prior month showed only a few “Room Visits by Staff” early in the month with no alternate or subsequent activities documented. Review of the February and March activity calendars showed repetitive, routine programming with the same activities at the same times on specific days, only faith-based activities on Sundays ending in the early afternoon, and no activities scheduled after mid-afternoon on several days. The administrator acknowledged that the activity program did not appear to engage residents, and the corporate activity coordinator confirmed limited oversight, lack of alternative activities when scheduled ones were not provided, and that Sunday activities were exclusively faith-based with at least one Sunday having no activities conducted.
Failure to Complete Thorough Admission Skin Assessment and Timely Wound Treatments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders and resident preferences by not thoroughly performing a skin assessment and not implementing timely wound treatments upon admission for one resident. The resident was admitted with diagnoses including surgical aftercare following digestive system surgery, hypertension, depression, and dysphagia, and had severely impaired cognition, requiring staff dependence for ADLs, transfers, and mobility. The admission skin assessment documented skin impairments on the right lower leg, right heel, and top of the right foot, but did not identify the type of skin impairment (such as skin tear, bruise, or pressure ulcer) and lacked descriptive details including color, drainage, and measurements. Physician orders and the treatment administration record showed that wound care treatments for the right lower leg, right heel, and top of the right foot were not ordered until three days after admission. The DON acknowledged awareness of the delay in implementing wound care treatments and stated that the admission nurse should have completed a thorough skin assessment and obtained treatment orders upon admission while awaiting a wound care consultation. The facility’s own Skin and Wound Guidelines required that wounds be evaluated and documented in the electronic medical record with specific elements, including wound type, location, measurements, wound bed tissue types, exudate, peri-wound condition, and treatment, and that treatment options be selected based on these characteristics, which was not done at the time of admission for this resident.
Significant Insulin Medication Error Resulting in ICU Admission
Penalty
Summary
A significant medication error occurred when a nurse administered 100 units of short-acting insulin to a resident instead of the prescribed 3 units. The error was due to the nurse misreading the insulin order, confusing the medication strength (100 units/ml) with the dose to be given. The nurse, who had limited experience with insulin administration and was new to bedside nursing in long-term care, did not seek clarification despite noticing the unusually large volume drawn up. The nurse also reported that another resident was prescribed a high dose of insulin, which contributed to her assumption that the dose was correct. The resident involved had a medical history including necrotizing fasciitis, type 2 diabetes mellitus, and a recent diagnosis of hypoglycemia. After receiving the excessive insulin dose, the resident experienced dizziness and a significant drop in blood sugar, requiring emergency intervention. The resident was given glucose by EMS or facility staff and was subsequently hospitalized in the intensive care unit for management of hypoglycemia. Record review and staff interviews confirmed that the nurse did not verify the correct dose before administration and failed to follow the facility's medication administration policy, which requires confirmation of the right dose. The incident was documented in the resident's clinical record, progress notes, and an incident report, all indicating that the error was recognized after administration and emergency measures were taken.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Activity Director Lacks Required Qualifications
Penalty
Summary
The facility failed to ensure that the Activity Director met the minimum qualifications required for the position, affecting all residents. During a review of employee documentation, it was found that the Activity Director, who was hired on 7/31/24, did not possess a license or certification as required. The Administrator confirmed that there was no license or certification on file for the Activity Director and that the individual had previously worked only as an activity assistant before assuming the director role. No additional work experience was provided for the past five years. Further review of the facility's job description for the Activity Director position indicated that the role requires either a relevant license or registration, two years of experience in a social or recreational program (with at least one year in a patient activities program in a healthcare setting), qualification as an Occupational Therapist or Occupational Therapy Assistant, or completion of an approved training course. The Activity Director did not meet any of these minimum qualification standards, as confirmed by the Administrator and the documentation provided.
Failure to Maintain Sufficient Nursing Staff
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents, as evidenced by multiple instances of low staffing, particularly on weekends. Facility-submitted data to CMS for the first quarter of the year showed excessively low nursing staffing on weekends. Staffing and sign-in sheets revealed repeated call-offs across several weekends, with the facility attempting but not always succeeding in filling these gaps. Interviews with CNAs, an RN, an LPN, and the facility scheduler confirmed ongoing staffing challenges, especially with CNAs, and frequent reliance on agency staff. Staff reported that when short-staffed, they had to modify care routines, such as providing bed baths instead of showers, and nurses had to assist with CNA duties. The scheduler and administrator acknowledged persistent issues with staff call-offs and open positions, and recent efforts to use agency staff to address shortages. A confidential group interview with residents revealed that some experienced delayed responses to call lights and missed showers, particularly on weekends and overnight shifts, due to insufficient staffing. Three out of ten residents specifically voiced concerns about long wait times and missed care. The facility assessment indicated that staffing was supposed to be based on resident population and acuity, but the reported events and interviews demonstrated that staffing levels were not consistently adequate to meet resident needs.
Failure to Update Facility Assessment and Staffing Plan After Unit Reopening
Penalty
Summary
The facility failed to update its facility-wide assessment and staffing plan after reopening a previously closed unit, 2 South, which was now being utilized and had residents assigned to rooms. Observations over several days confirmed that all units, including 2 South, were in use. However, the most recent facility assessment still indicated that 2 South was not being staffed due to census, and there was no documentation of a revised staffing plan for this unit. The assessment's section for review and update after significant changes had not been initialed or dated to reflect the reopening and active use of 2 South. The Administrator acknowledged that the assessment had not been updated to include the staffing plan for the reopened unit.
Inaccurate MDS Assessments for Resident with Physical Impairments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for a resident with significant physical impairments. The resident, who had an above-the-knee amputation of the left leg and a contracted left hand, was repeatedly documented in MDS assessments as having no impairment in upper or lower extremities. Observations confirmed the resident was unable to move the fingers of the left hand, and an occupational therapy evaluation documented contractures and impaired range of motion in the left hand and fingers. Despite these findings, multiple MDS assessments over time, signed by a registered nurse who was not regularly present at the facility, indicated no impairment. The assessments were often completed offsite and based on chart review rather than direct evaluation or input from direct care staff. Interviews with facility staff revealed that the MDS nurse was new and still in training, and the registered nurse responsible for signing the assessments was not physically present at the facility. The regional MDS nurse stated that assessments were completed as chart reviews and justified the lack of impairment documentation by referencing occupational therapy notes that indicated the contracture did not affect functional skills. However, the resident's inability to use the left hand and the presence of an amputation were not accurately reflected in the MDS documentation, despite being longstanding conditions noted in the clinical record and care plan.
Improperly Sealed Window AC Units Allow Insect Entry
Penalty
Summary
The facility failed to ensure that window air conditioning units were properly sealed, resulting in gaps at the sides and bottom of the units in rooms occupied by two residents. During observations, one resident was found lying in bed with a green insect with wings present on the pillowcase near their head. Further inspection of the same room revealed the window AC unit remained poorly sealed, and another similar insect was observed on the window sill. The Maintenance Director confirmed the improper sealing of the AC units during the inspection. The facility's policy requires a safe, clean, and comfortable environment, including clean bed linens in good condition, but the presence of insects and unsealed AC units indicated noncompliance with this policy.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency for one resident who was severely cognitively impaired and unable to explain the cause of their injuries. The resident, who had diagnoses including epilepsy, diabetes, recurrent falls, and paranoid schizophrenia, was found with facial bruising and swelling by a family member during a visit. The clinical record indicated that the injury was first documented by a physician, with no prior notes describing the resident's facial condition or when the injury was discovered. The incident/accident report described the family member finding blood and bruising, and the resident was unable to provide an explanation due to their cognitive status. Staff statements indicated that the injury was not witnessed, and the resident later claimed to have punched themselves, but this was reported three days after the injury was observed. The resident's legal guardian expressed doubt that the resident could have self-inflicted the injuries and suggested a possible fall, but no one could confirm the cause. Despite the facility's policy requiring immediate reporting of injuries of unknown source to the State Agency, the injury was not reported as such. The Administrator and staff did not consider the incident to be of unknown origin, relying on the resident's delayed and questionable statement of self-harm, despite the resident's severe cognitive impairment and inability to reliably communicate. The facility's failure to report the injury as required by policy and regulation constituted the deficiency identified by surveyors.
Failure to Conduct Care Planning Review After Significant Change for Hospice Resident
Penalty
Summary
The facility failed to conduct a care planning review in coordination with a significant change Minimum Data Set (MDS) assessment for a resident who was receiving hospice care. The resident, who had multiple diagnoses including palliative care needs, severe cognitive impairment, and memory loss, was admitted, hospitalized, readmitted, and then signed onto hospice services. Despite the completion of a significant change MDS assessment, there was no documentation of a care planning review involving the resident, their legal representative, the interdisciplinary team, or hospice staff after the resident began hospice care. The only documented care conference occurred shortly after admission, with no subsequent reviews noted in the clinical record following the significant change in the resident's condition. Interviews with facility staff confirmed that a care planning review had not been completed as required. The Social Work Director acknowledged responsibility for coordinating the care conference but admitted it had not yet been done. Additionally, the hospice nurse reported not being involved in any care planning review with the resident, legal representative, or facility staff after the resident started hospice care. The facility's own policy requires care conferences to be offered on admission, quarterly, with significant changes in condition, and upon request, but this was not followed in this case.
Failure to Provide Showers and Proper Hygiene Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who required a two-person assist with a mechanical lift for all transfers and had a body weight between 362-375 pounds, did not receive showers since admission. The resident, who was alert and able to communicate needs, reported not having a shower due to the facility lacking a chair large enough for use in the shower room. Documentation review confirmed that only bed baths were provided on specific dates, with no record of showers being given or refused. The resident's care plan and Kardex lacked instructions or documentation regarding bathing or shower preferences and concerns. Interviews with facility staff revealed uncertainty about the availability of appropriate equipment, with one nurse stating that the facility did not have a suitable chair and another suggesting a shower bed might have been available but believed the resident refused it, though no refusal was documented. The facility's policy required provision of care to maintain personal hygiene for residents unable to perform activities of daily living independently, but this was not followed in the resident's case.
Delay in Pressure Ulcer Treatment Leads to Stage 3 Wound
Penalty
Summary
A resident with diagnoses including dementia, heart disease, and kidney disease, and with severely impaired cognition, was admitted to the facility and later developed a facility-acquired Stage 3 pressure ulcer. On initial assessment, a wound was identified on the resident's sacrum by an LPN, who reported the finding to the wound care nurse and applied a dressing. However, the LPN did not document a progress note or notify the physician for wound treatment orders at that time. There was a delay in obtaining treatment orders and implementing interventions, as the wound care nurse was not present on weekends and only initiated appropriate care two days after the wound was first identified. The contracted wound provider subsequently assessed the wound and documented it as a Stage 3 pressure injury. The facility's acting Director of Nursing acknowledged that the delay in treatment orders and interventions contributed to the development of the Stage 3 pressure ulcer.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of shortness of breath, obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD) was not provided oxygen therapy as ordered by the physician. The resident, who was cognitively intact, was observed lying in bed with a nasal cannula in place, but the oxygen concentrator was set to deliver 0 liters and was not running. The resident confirmed that they were supposed to be on 2 liters of oxygen. Upon further inspection, it was found that the concentrator was not plugged in, and there was no audible sound indicating it was operational. A nurse confirmed that the resident was supposed to be on oxygen and subsequently plugged in the concentrator. Record review showed a physician's order for continuous oxygen at 2 liters via nasal cannula. During an interview, the respiratory therapist stated that the resident used oxygen for comfort but acknowledged that the order in the system was for continuous use and should have been followed. The failure to administer oxygen as ordered was not addressed until it was brought to staff attention during the survey.
Failure to Ensure Timely Acquisition and Administration of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of medication for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including Alzheimer's disease, dementia with agitation, and anxiety disorder. The resident had physician orders for two different dosages of quetiapine (Seroquel), an antipsychotic medication, to be administered at specific times. Documentation in the Medication Administration Records (MARs) indicated that the medication was on order on one date, but was marked as administered on subsequent dates. However, when a nurse was questioned about the administration and asked to check the medication cart, it was found that there was no medication card (blister pack) for the Seroquel, and the nurse could not confirm whether the medication had been administered or pulled from the back-up supply. Further review by facility leadership and pharmacy records revealed that there was no documentation of Seroquel being pulled from the back-up supply for the month in question, and the medication card showed that the Seroquel was not delivered until several days after it was ordered. There was also a lack of documentation for the relevant period and no evidence that the medication was available or administered as ordered. This sequence of events demonstrates a failure in the facility's process for ensuring the timely acquisition and administration of necessary medications to meet the needs of the resident.
Failure to Implement Enhanced Barrier Precautions for Resident with New Pressure Ulcer
Penalty
Summary
The facility failed to implement infection control practices related to Enhanced Barrier Precautions (EBP) for a resident with a newly identified pressure ulcer. Upon observation, there was no signage or PPE cart outside the resident's room to indicate EBP was in place, despite other rooms in the hallway having appropriate signage. The resident, who had multiple diagnoses including palliative care, chronic respiratory failure, and diabetes, was found to have a new pressure ulcer on the left gluteus, with wound care orders initiated by the wound care nurse. However, there was no physician order for EBP, nor was EBP implemented at the time the wound was identified. Interviews with staff revealed that the wound care nurse believed EBP was in place, but acknowledged the lack of signage, PPE cart, and physician order when questioned. The Infection Preventionist/ADON stated they were not informed of the new wound and that the process for implementing EBP typically involved the nurse who discovered the wound. The facility's policy required EBP, signage, and PPE availability for residents with wounds, but these measures were not followed for this resident.
Failure to Timely Identify and Document Scalp Wound
Penalty
Summary
The facility failed to timely and accurately assess, treat, and follow up with a medical provider for a change in condition for one resident who was dependent on staff for most activities of daily living and had intact cognition. The resident was admitted without skin abnormalities, and weekly skin assessments were not consistently documented, with a gap in documentation after an assessment on 7/5. On 7/14, the resident reported a sore area on the back of the head, which was found to be red, warm, and draining. Nursing staff notified the nurse practitioner, who ordered antibiotics, but the resident's son insisted on hospital transfer after observing the wound. The resident was subsequently sent to the hospital by EMS. Hospital evaluation revealed a scalp wound with cellulitis and foul-smelling purulent discharge, with wound cultures showing Staph aureus and Proteus mirabilis. Interviews with facility leadership indicated that the wound was not identified prior to the day of hospital transfer, despite daily care by CNAs and the expectation of weekly skin assessments. The Assistant Director of Nursing acknowledged that the wound should have been identified earlier and that required documentation was missing. The lack of timely identification and documentation of the wound led to the resident's transfer for advanced medical care.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for five out of six residents reviewed for accommodation of needs. Multiple observations showed that residents were either lying in bed crying or sleeping, with their call lights found hanging out of reach or on the floor, sometimes tangled with other cords. Staff, including an LPN and an RN, entered and exited a resident's room without ensuring the call light was accessible. Despite care being provided by CNAs in several rooms, the call lights for these residents remained inaccessible throughout the observed period. The residents affected had significant medical conditions, including encephalopathy, vascular dementia, quadriplegia, Alzheimer's disease, and were at risk for falls. Their care plans and assessments indicated varying levels of cognitive impairment and dependence on staff for activities of daily living, with specific instructions for call lights to be within reach or placed in a particular position. Interviews with nursing staff and the DON confirmed that ensuring call lights are accessible is a shared responsibility among the nursing team, and that staff had been previously educated on this requirement.
Plan Of Correction
F 558 ELEMENT 1 It is the practice of the facility to provide reasonable accommodation of resident needs and preferences to include but not limited to ensuring call lights are within reach for the residents. R605, R606, R607, R608, and R609 call light were relocated to ensure they were within reach before the end of the survey. ELEMENT 2 Residents that currently reside in the facility have the potential to be affected by this cited practice. Residents have been reviewed to ensure call lights are within reach. Any deficiencies have been immediately corrected. ELEMENT 3 The Interdisciplinary Team reviewed the Call Light policy and deemed it appropriate. Staff have been educated on the Call Light policy with emphasis on ensuring the residents' call lights are within reach. ELEMENT 4 The DON/designee will complete random audits on 5 residents a week for 4 weeks, then 5 residents a month for 2 months to ensure call lights are within reach. Any deficient practice will be corrected/updated immediately. The results will also be taken to the Quality Assurance and performance review meeting. The Administrator and/or designee is responsible for compliance. Compliance Date: 5/8/25
Resident Bathroom Maintenance Failure
Penalty
Summary
The facility failed to maintain a resident bathroom in a clean, comfortable, and safe manner, affecting one resident who had to change clothing frequently due to water leaking from the ceiling. The resident expressed frustration and concern over the situation, which had persisted for seven days. During an observation, the bathroom was found to have a plastic bin collecting liquid from the ceiling, a strong foul odor, and multiple flying insects. The ceiling showed signs of water damage, including discoloration and cracks, with dark brown, raised, circular areas observed on the surface. Interviews with the Maintenance Director and the Director of Nursing revealed that the issue was known to them only recently, despite the resident's report of the problem persisting for a week. The Maintenance Director confirmed the water damage and was in the process of fixing the leak, which originated from a toilet in the bathroom above. The Director of Nursing acknowledged that staff were required to report maintenance issues and that the residents should have been moved from the affected room. The resident, who had intact cognition and was admitted with diagnoses including cancer, type 2 diabetes, and chronic kidney disease, was tearful when discussing the issue.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications according to the Physician's orders for a resident, identified as R801, who was reviewed for medication administration. On the morning of January 15, 2025, R801 reported that they had not received their Synthroid or regular Tylenol, a situation they claimed occurred frequently. R801, who has diagnoses of Hypothyroidism and Osteoarthritis, was observed in the hallway in their wheelchair and expressed concerns about the facility missing their medications. A review of R801's medical record showed that they had a BIMS score of 15, indicating intact cognition, and had specific Physician's orders for Synthroid and Acetaminophen, which were not administered as scheduled at 6:00 a.m. Upon investigation, Nurse D confirmed that the medications were not administered and mentioned plans to call the Physician for one-time orders to administer them later. The Director of Nursing (DON) acknowledged that R801 does not prefer the midnight Nurse to administer their medications, leading to a process where a Nurse from another side of the floor is responsible for doing so. However, the DON stated that this was not an acceptable reason for the failure to administer the medications. The facility's Medication Administration policy was reviewed, which emphasized the importance of administering medication according to physician orders and professional standards of practice.
Failure to Implement Specialist's Recommendations for Resident Care
Penalty
Summary
The facility failed to implement the recommendations from an orthopedic specialist for a resident, identified as R802, who was reviewed for coordination of care to outside appointments. R802, who has rheumatoid arthritis and foot drop of the left foot, was observed having difficulty moving their arm and expressed concerns about the facility not following through with specialist recommendations. The resident reported that a brace for their foot was recommended by an outside provider, but the facility staff did not apply the device, stating it would not help. R802 was unsure if the device was even available for use. A review of R802's clinical records showed that the orthopedic doctor recommended compression socks and an ankle foot orthosis (AFO) brace, which were not ordered or documented in the resident's physician orders as of a month after the consultation. The Director of Nursing (DON) explained that consultation reports are reviewed, and if the physician agrees, orders are entered into the electronic medical record. However, there was no documentation justifying the lack of implementation of the specialist's recommendations, indicating a failure in coordinating and implementing necessary care for the resident.
Neglect in Medication Administration Leads to Resident Distress
Penalty
Summary
The facility failed to ensure freedom from staff neglect for a resident, resulting in a significant delay in the administration of an anti-anxiety medication. The resident, who was cognitively intact and had a history of anxiety disorder, requested Ativan, an anti-anxiety medication, which was ordered by the physician and entered into the system by a nurse consultant. However, the medication was not administered until approximately four hours later, despite the resident's repeated requests and the order being confirmed in the system. The delay was primarily due to the actions and inactions of an LPN, who was responsible for administering the medication. The LPN claimed not to have seen the order in the system and prioritized taking a break over administering the medication, despite being informed by the Administrator and another RN that the order was in place. The LPN's refusal to administer the medication led to an altercation with the resident, who became increasingly anxious and frustrated, ultimately resulting in a physical confrontation. The incident was further complicated by the LPN's inappropriate behavior, including threatening to involve her husband in the situation and using inappropriate language. Witness statements from other staff and residents corroborated the resident's account of the LPN's neglect and unprofessional conduct. The facility's investigation concluded that the LPN neglected to provide the necessary care, leading to the resident's distress and the subsequent altercation.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility staff failed to timely report allegations of sexual abuse involving a resident, identified as R901, who was severely cognitively impaired with a BIMS score of 5/15 and had a court-appointed guardian. On or about 9/25/24, an outside male visitor allegedly engaged in inappropriate conduct with R901, who was unable to recall the incident due to dementia. The incident was observed by a Certified Nursing Assistant (CNA H), who found the visitor zipping up his pants in R901's room, which was unusual as the door was typically open. Despite witnessing the incident, CNA H did not report it to the Administrator/Abuse coordinator as required by the facility's policy. Instead, CNA H informed another CNA (CNA C), who also failed to report the incident to the appropriate authorities. The delay in reporting was further compounded when CNA C informed a third CNA (CNA L), who was preoccupied with personal commitments and did not report the incident promptly. The facility's policy mandates that all allegations of abuse be reported to the Administrator and the State Survey Agency immediately, or within two hours if the allegation involves abuse. The Administrator confirmed that the staff did not adhere to this policy, resulting in a delay in reporting the alleged abuse to the proper authorities. This failure to report in a timely manner constitutes a deficiency in the facility's handling of abuse allegations.
Failure in Pest Control Program Leads to Insect Presence
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats, house flies, and sewer flies throughout the building, including the basement. This issue was identified during a survey conducted on 9/18/24, where multiple observations of flying insects were made. A significant contributing factor was the missing bottom door seal on the emergency exit/delivery door in the first-floor north hallway, which allowed outside light and potentially insects to enter. The Maintenance Director, who had been in their role since 2022, was unaware of the missing door seal and confirmed the issue during the survey. The facility's pest control documentation showed service dates but did not address the missing door seal or the presence of flying insects. The Director of Nursing (DON) confirmed the presence of flies during the survey and acknowledged the need for better communication regarding pest concerns. The facility's policy on pest control required monitoring by staff and prompt reporting of issues to the Environmental Services Director, but there was no documentation of insect concerns in the facility's electronic work orders since 7/1/24. The DON recognized the need for additional education on reporting environmental issues.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, affecting multiple residents. Observations revealed several issues, including loose wires hanging from the building near a water spout, a wall heater register hanging down, and trash and debris under a resident's bed. Additionally, a privacy curtain was not secured, and the bottom door seal to an emergency exit was missing, allowing outside light to be visible. A shared bathroom had bunched-up toilet paper with a brown substance, water damage, mold-like substances, and peeling paint. The shower room had a soiled shower chair and mold-like debris on the tiles and grout. Staff interviews indicated a lack of awareness and communication regarding these environmental concerns. Floor Care staff reported they did not clean resident bathrooms, and the Maintenance Director was unaware of several issues, including hanging wires and water damage. The Director of Nursing (DON) confirmed the environmental concerns but noted that staff should have reported these issues through electronic work orders. However, a review of the work order records showed no mention of the identified concerns. The facility's policy on maintaining a homelike environment emphasized the importance of a clean, sanitary, and orderly setting. It required staff to report any environmental concerns to the appropriate departments. Despite this policy, the facility's staff failed to report or address the observed deficiencies, leading to the citation. The DON acknowledged the need for additional education on reporting environmental issues, as the current system did not capture the existing problems.
Unsecured Portable Oxygen Tank Poses Hazard
Penalty
Summary
The facility failed to ensure that a portable oxygen tank was properly secured, posing a potential hazard. During an observation, a resident was found in bed with an oxygen concentrator in use, set to three liters via nasal cannula. Next to the resident's bed were two portable oxygen tanks; one was secured in a metal holder, while the other was left free-standing near the resident's head. The resident indicated that the unsecured tank was empty and was unsure of how long it had been in that state. A nurse, upon being informed of the situation, confirmed the unsecured tank and acknowledged that it should not have been left in such a manner. The resident had been admitted with diagnoses including non-ST elevation myocardial infarction, chronic obstructive pulmonary disease, and emphysema, with physician orders for oxygen delivery as needed for shortness of breath. The facility's policy mandates that oxygen cylinders be secured by chains, racks, or stands, and the observed deficiency was a deviation from this policy.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure proper medication storage for a resident, identified as R406, when a single white circular pill was found on the resident's bedside table. The resident was not present in the room at the time of observation. Nurse 'C', who was responsible for administering medications, confirmed the pill was carvedilol, a medication for high blood pressure, which was supposed to be given at 9:00 AM and 9:00 PM, not at 6:00 AM as initially indicated. Nurse 'C' mentioned that the medication had been held earlier due to a low blood pressure reading of 106/72. However, the pill was left unsecured at the bedside, contrary to the facility's policy that requires medications to be under direct observation or locked in the medication storage area/cart during administration. The resident, R406, had a history of cerebral infarction, acute metabolic acidosis, encephalopathy, mild cognitive impairment, essential hypertension, hemiplegia, chronic systolic heart failure, paroxysmal atrial fibrillation, and hyperlipidemia. The resident was deemed incompetent to make medical decisions due to moderately impaired reasoning and executive decision-making. The facility's documentation showed that the carvedilol was last documented as given on the previous evening, and the medication administration record indicated that the medication was held due to vital signs being outside the parameters for administration. The Director of Nursing was informed of the incident and acknowledged that no medication should be left at the bedside.
Failure to Prevent Resident Fall Due to Inadequate Supervision and Hazardous Environment
Penalty
Summary
The facility failed to complete appropriate assessments and provide necessary interventions for a resident, resulting in a fall from bed. The resident, who had intact cognition and was a long-term resident with diagnoses including osteoarthritis, stroke, and a benign brain tumor, experienced a fall while being assisted by staff. The incident occurred when the resident attempted to grab the armrest of a chair for support during care, but the chair was broken, leading to the fall. The resident's care plan required one-person assistance for bed mobility, but the staff member assisting the resident was positioned incorrectly, standing on the right side and pushing the resident harder than necessary, causing the resident to roll out of bed. The facility's fall management guidelines were not adequately followed, as the staff did not use proper techniques for bed mobility, and the resident's environment was not free from hazards, as evidenced by the broken chair. The incident report and subsequent evaluations revealed that the staff member failed to appropriately position the resident during care, and the facility did not have assistive devices in place prior to the fall. The resident's care plan included interventions such as keeping the bed in a low position and using assist bars, but these were only implemented after the fall occurred. The facility's failure to adhere to its own fall management guidelines and provide a safe environment contributed to the resident's fall.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect three residents (R33, R35, and R21) from physical and verbal abuse by staff and other residents. R33, a long-term resident with moderate cognitive impairment, was physically and verbally abused by an LPN approximately six months prior to the investigation. The abuse was witnessed by a CNA who failed to report it immediately due to fear of the perpetrator. The incident was only reported to the local police department 21 hours after it was brought to the attention of the abuse coordinator. Both the perpetrator and the witness were terminated after the investigation was completed. R35, a resident with severely impaired cognition, was physically assaulted by their roommate, R50, who had a history of aggressive and threatening behaviors. The incident occurred when R35 attempted to propel their wheelchair by grabbing R50's bed, prompting R50 to strike R35 multiple times. Despite the known aggressive behavior of R50, the facility did not document the incident in R50's progress notes, and the Administrator was unaware of the incident until the survey. R21, a resident with intact cognition, experienced verbal abuse from their roommate, R61, who made antisemitic slurs. R21 reported the incident to the Administrator and was subsequently moved to a different room. However, there was no documentation in R21's record explaining the reason for the room change, and no investigation reports or grievances were provided by the facility. R61 had a documented history of behavioral concerns, including anger and inappropriate language towards staff and other residents.
Failure to Report Abuse and Neglect Timely
Penalty
Summary
The facility failed to report actual and alleged physical and verbal abuse to the Abuse Coordinator, law enforcement, and/or the State Agency within the required time frame for six of 11 residents reviewed for abuse. This resulted in a significant delay in investigating incidents, including a six-month delay in investigating physical abuse of a resident by a staff member who continued to work in the facility during that time. The incidents involved both resident-to-resident abuse and staff-to-resident abuse, with multiple failures in timely reporting and documentation of these events. One incident involved a resident physically assaulting another resident by hitting them multiple times in the head. The incident was witnessed by a CNA and reported to an RN, who then contacted the Director of Nursing (DON) and the resident's family but was unable to reach the Administrator, who was the facility's Abuse Coordinator. The Administrator later claimed to be unaware of the incident until much later, and the incident was not reported to the State Agency as required. Another incident involved a resident making serious allegations of abuse against a staff member, which were reported to the Assistant Director of Nursing (ADON) but not properly documented or reported to the State Agency. The ADON and DON interviewed the resident but did not find any specific information about the abuse, and the allegations were deemed unfounded without further investigation. Additionally, there were incidents of verbal abuse and antisemitic slurs between residents that were reported to the Administrator but not documented or reported to the State Agency, with the Administrator deciding not to report the incidents based on their judgment of the residents' safety after room changes.
Failure to Investigate Resident Abuse and Injuries
Penalty
Summary
The facility failed to investigate witnessed and alleged resident-to-resident physical and verbal abuse and did not thoroughly investigate a bruised eye of unknown origin for five residents. One incident involved a resident physically assaulting another resident multiple times in the head. Despite the incident being witnessed and reported by a CNA, the facility's Administrator, who is also the Abuse Coordinator, was unaware of the incident until much later and no thorough investigation was conducted. The clinical records of the involved residents did not document the incident, and the facility failed to determine the root cause or implement measures to prevent future occurrences. Another incident involved a resident experiencing verbal abuse from their roommate, including antisemitic slurs. The resident reported the incident to the Administrator, who allowed a room change but did not conduct a full investigation or report the incident to the State Agency. The facility did not provide any documentation of the incident or investigation, and the Administrator believed the room change was sufficient to ensure the resident's safety. A third incident involved a resident with severe cognitive impairment who was found with bilateral orbital trauma of unknown origin. The facility's investigation attributed the trauma to the resident's use of blood-thinning medications and sleeping habits but did not include a physical trauma evaluation. Witness statements were limited to observations of the resident without trauma, and the facility did not establish a clear timeline of the injury. The Administrator was unable to provide a satisfactory explanation for the incomplete investigation and documentation.
Failure to Honor Resident's DPOA Wishes for Code Status
Penalty
Summary
The facility failed to ensure that the resident's active Durable Power of Attorney (DPOA) wishes for their family member's code status were accurately followed for one resident. The resident, who had diagnoses including Parkinsonism, vascular dementia, and depressive disorder, was initially admitted with a Do-Not-Resuscitate (DNR) status as indicated by their DPOA. However, a conflicting document signed by another family member changed the resident's code status to FULL CODE, which was not in accordance with the DPOA's wishes. The resident was deemed incompetent and unable to make their own decisions, further complicating the situation. The discrepancy was discovered during an interview and record review with a social worker, who confirmed that only the resident's legal representative has the right to change the resident's code status. The facility's policy on advance directives was not followed, leading to the failure to honor the resident's DPOA's wishes. The social worker contacted the DPOA to clarify the advanced directive, confirming that the resident's correct status was DNR, as initially indicated by the DPOA.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) for one resident who was admitted for skilled rehabilitation and nursing services after hospitalization. The resident's diagnoses included sepsis, acute respiratory failure, and muscle weakness. The Minimum Data Set (MDS) assessment indicated moderate cognitive deficits. The resident reported that their therapy services ended due to insurance, and a review of the Electronic Medical Record (EMR) confirmed that skilled services ended on 5/6/24. However, the resident or their legal representative did not receive the required beneficiary notices prior to the termination of Medicare Part A services. An interview with the Business Office Manager revealed that the facility missed providing the notices due to a transition period within the social work department, during which there was no social worker onsite. The Administrator was informed of the issue and acknowledged the concern. The failure to provide the NOMNC resulted in the resident and/or their representative not being informed of their right to appeal, potentially leading to undue emotional and financial hardships.
Failure to Ensure Accurate MDS Assessments
Penalty
Summary
The facility failed to ensure accurate assessments were completed for one resident reviewed for Minimum Data Set (MDS) assessments. The resident, who was admitted with Wernicke's encephalopathy, had multiple instances of refusing care, medications, treatments, and services almost daily, including rehabilitation services, being weighed, and laboratory services. Despite these refusals, the resident's most recent quarterly and previous comprehensive annual MDS assessments inaccurately documented that the resident had no behaviors, including no rejection of care, during the respective seven-day look-back periods. The MDS Coordinator confirmed that the assessments should have been accurate and that the social services department completed the behavior section of the MDS assessments, which she then checked for accuracy and signed off on.
Failure to Complete Required PASARR Screenings
Penalty
Summary
The facility failed to ensure that a Level I Preadmission Screening (PAS) and Annual Resident Review (ARR) for Mental Illness/Intellectual Disability/Related Conditions Identification was completed on admission and/or annually for two residents. Resident R7 was admitted with diagnoses including schizophrenia and dementia with behavioral disturbances. Despite having a Level I screening completed in the hospital, which indicated the need for a Level II screening due to mental illness and antipsychotic medication use, no further PASARR screenings were completed after R7 remained in the facility beyond the expected 30 days. Similarly, Resident R67, admitted with diagnoses including anxiety disorder, major depressive disorder, psychotic disorder with hallucinations, and dementia, had a Level I screening completed upon admission, but no subsequent Level II screening was conducted, nor was an annual Level I screening completed since 2022. Both residents' Minimum Data Set (MDS) assessments inaccurately marked them as not being considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite their documented diagnoses and treatments for mental illness. An interview with the Director of Social Services confirmed that the facility failed to complete the necessary Level I and Level II screenings for both residents. The Director acknowledged that R7 should have had both screenings completed by the facility after staying longer than 30 days, and R67 should have had annual screenings. This oversight indicates a lapse in the facility's compliance with PASARR requirements, potentially impacting the appropriate care and services provided to residents with serious mental illness or intellectual disabilities.
Failure to Monitor Blood Pressure in Resident with Hypertension
Penalty
Summary
The facility failed to consistently monitor the blood pressure of a resident who was prescribed multiple medications to treat high blood pressure. The resident, who had diagnoses including lupus and hypertension, was found unresponsive and unable to sit upright in bed on the morning of 4/25/24. The resident's blood pressure was recorded at 189/93 mmHg, indicating a hypertensive crisis, and the resident was subsequently transferred to the hospital. Hospital records indicated that the resident presented with altered mental status and an increased blood pressure of 196/120 mmHg upon admission, with a note suggesting that the resident may have missed their medications. A review of the resident's clinical records revealed that the last documented blood pressure reading was on 4/15/24, ten days prior to the emergency transfer. The resident's care plan included instructions to obtain vital signs and notify the physician as needed, but there were no specific parameters for blood pressure monitoring. The Assistant Director of Nursing confirmed that in the absence of ordered parameters, vital signs should be taken each shift. However, no additional blood pressure readings were documented between 4/15/24 and 4/25/24, indicating a failure to monitor the resident's condition adequately during this period.
Failure to Follow Physician Orders for Assistive Devices
Penalty
Summary
The facility failed to follow the recommendations and physician orders for assistive devices to maintain range of motion and positioning for two residents, resulting in the potential for decline in range of motion and worsening of contractures. Resident 12, who had severe cognitive deficits and multiple diagnoses including hemiplegia and joint contractures, was observed multiple times without the prescribed left elbow brace and left palm protector. The physician's order and care plan specified the use of these devices, but they were not applied as required. The information about the brace and palm protector was also missing from the resident's Kardex, which was only updated after the issue was raised with the facility staff. Resident 30, who had intact cognition and required extensive assistance for mobility and ADLs, was also observed multiple times without the prescribed left palm protector. The resident reported not knowing the location of the brace. The care plan included the use of the palm protector, but this information was not reflected in the resident's Kardex. Interviews with the restorative aide and the interim DON revealed that the restorative aide was responsible for applying the splints and braces but faced challenges due to other priorities and lack of oversight. The facility's policy on restorative nursing emphasized maintaining or improving residents' abilities to the highest practicable level, but the observations and interviews indicated a failure to adhere to this policy. The restorative aide reported difficulties in completing all tasks due to other responsibilities, and the interim DON acknowledged the concern and the need for follow-up. The lack of proper application and documentation of assistive devices for these residents highlights a significant deficiency in the facility's care practices.
Inadequate Supervision and Positioning During Care
Penalty
Summary
The facility failed to provide appropriate supervision and positioning during showers and therapy for two cognitively impaired residents, resulting in significant injuries. Resident R436, who had severe cognitive impairment and required supervision for showers, fell in the shower room and sustained compression fractures to the thoracic vertebrae. Despite being instructed to sit on a shower chair, R436 was left unsupervised, leading to the fall. The resident's care plan indicated the need for assistance during bathing, but this was not adequately followed, resulting in severe back pain and the need for a back brace and hospital visit for further evaluation and treatment. Resident R11, also with severe cognitive impairment and requiring assistance for all activities of daily living, fell during a physical therapy session. While receiving range of motion exercises in a wheelchair, R11 began rocking back and forth, lost balance, and hit their head against the wall before the wheelchair flipped over. The physical therapy assistant attempted to minimize the fall, but R11 still sustained a head injury. The incident highlights a lack of appropriate positioning and supervision during therapy sessions for residents with severe cognitive impairments.
Failure to Implement Psychiatrist's Recommendations for Resident's Mental Health Care
Penalty
Summary
The facility failed to implement the recommendations made by a contracted behavioral health provider for a resident diagnosed with multiple mental health disorders, including dementia with psychotic disturbance, anxiety disorder, adjustment disorder, psychotic disorder with hallucinations, and major depressive disorder. Despite the psychiatrist's recommendations on 3/25/24 to taper Seroquel, start Risperdal, increase Remeron, and consider a room change, these actions were not taken in a timely manner. The resident's Seroquel dose was not adjusted, Risperdal was not started, and Remeron was not increased as recommended. Additionally, the room change was delayed by 14 days. Interviews with the Director of Social Services and the Assistant Director of Nursing revealed that there was a lack of follow-up to ensure the psychiatrist's recommendations were implemented. The Director of Social Services confirmed that the recommended orders were not implemented, and the Assistant Director of Nursing indicated that both the psychiatrist and the facility's staff were responsible for ensuring the orders were followed. The failure to implement these recommendations was confirmed through record reviews and staff interviews, highlighting a significant lapse in the facility's care for the resident's mental health needs.
Failure to Evaluate Competency and Obtain Guardianship for Cognitively Impaired Resident
Penalty
Summary
The facility failed to evaluate the competency and obtain guardianship for a resident with severely impaired cognition who did not have a resident representative. The resident, identified as R35, was observed in a disheveled state, wearing stained clothing and appearing confused. A review of R35's clinical record revealed a diagnosis of vascular dementia and severely impaired cognition, but there was no documentation indicating that R35 had a legal guardian or advance directive. Additionally, there was no evidence that R35 had been evaluated for competency to make medical decisions. During an interview, the Director of Social Services (SW 'J') confirmed that R35 was his own decision maker and acknowledged that a competency evaluation was required due to R35's cognitive status. SW 'J' explained the facility's process for determining decision-making capacity, which includes a competency evaluation by a physician and psychologist, and initiating guardianship if necessary. However, this process had not been followed for R35. The facility's policy on advance directives also outlined the need for assessing decision-making capacity and obtaining guardianship, but this had not been implemented for R35.
Failure to Accurately Document and Reconcile Controlled Medications
Penalty
Summary
The facility failed to accurately document and reconcile two controlled medications for one resident during a random surveillance of the narcotic drawer. During a medication storage observation, it was found that the narcotic binder documented 12 capsules of Gabapentin 100 mg, while the blister pack contained only 11 capsules. Similarly, the narcotic binder documented 13 tablets of Clonazepam 0.5 mg, while the blister pack contained only 12 tablets. The LPN acknowledged that both medications were administered to the resident prior to the observation but were not signed off in the narcotic binder. The Assistant Director of Nursing confirmed that medications are to be documented in the narcotic binder as soon as they are administered, as per the facility's policy for Medication Administration issued on 8/7/2023.
Failure to Schedule Follow-Up Dental Services for Resident
Penalty
Summary
The facility failed to schedule follow-up dental services for a long-term care resident, R236, who had multiple fractured teeth and moderate cognitive impairment. Despite a dental consult being noted in the resident's Electronic Medical Records (EMR) from 9/7/21 and a refusal of a dental visit on 2/14/23, there were no further attempts to obtain a dental appointment for R236. The resident's legal guardian had expressed concerns regarding the dental follow-up, but no actions were taken after 2/24/23 to address these concerns. Observations on 5/13/24 and 5/14/24 revealed that R236 was experiencing discomfort and bleeding from their teeth, and the resident expressed a need for dental assistance to the surveyor. Interviews with the covering Social Worker and the Assistant Director of Nursing (ADON) confirmed that the facility had a process for routine dental visits and assistance with scheduling appointments for special procedures. However, both the Social Worker and ADON acknowledged that there was no follow-up documentation or additional dental visits for R236 after the initial consults. The ADON and Social Worker understood the concern and indicated they would follow up, but at the time of the survey, no further actions had been documented.
Failure to Provide Timely Physical Therapy Services
Penalty
Summary
The facility failed to provide timely skilled rehabilitation services as ordered for a resident, resulting in a delay in evaluation for physical therapy services. The resident, who had diagnoses including polyneuropathy, liver failure, spinal stenosis, and osteoarthritis, reported needing physical therapy and had been waiting for a long time. Despite multiple follow-up observations and inquiries from the resident between 5/13/24 and 5/15/24, no recent physical therapy screening or evaluation was found in the resident's records. The resident's hospice progress notes also indicated that physical therapy had not started despite multiple requests dating back to January 2024. Interviews with the Director of Rehabilitation (DOR) and the Business Office Manager (BOM) revealed that there was awareness of the request for physical therapy from both the hospice and the resident. However, the DOR was waiting for approval from the administration/business office, and the BOM was trying to resolve who would cover the services. The BOM shared that the first communication regarding the physical therapy request was on 4/4/24, with a follow-up on 4/8/24, and a handwritten physician order dated 3/14/24 was not transcribed into the resident's electronic medical records. The Assistant Director of Nursing (ADON) acknowledged the concern and the delay in following up on the physical therapy request. The facility's policy stated that an initial evaluation should be completed within two days from the time the referral is written, but this was not adhered to in this case. The lack of timely follow-up and coordination between the facility and hospice services led to the resident's prolonged wait for necessary physical therapy services, causing frustration and a delay in addressing the resident's mobility needs.
Failure to Inform Legal Guardian of Significant Events and Medical Recommendations
Penalty
Summary
The facility failed to inform a resident's legal guardian of several significant events and medical recommendations. The resident, who had severe cognitive impairment and a court-appointed legal guardian, changed rooms without any documentation indicating that the guardian was informed. Additionally, the resident was seen by a neurologist, and several recommendations were made, including medication adjustments and physical therapy, but there was no record of the guardian being notified of these recommendations. Furthermore, the resident's immunization record showed a refusal for the influenza vaccine, but there was no indication that the guardian was informed about the vaccine offer or the refusal. The facility's policy requires notifying the resident's designated representative of changes in medical condition, room changes, and new treatments. However, the facility did not follow this policy in the case of this resident. The new administrator and regional nurse consultant confirmed that the guardian should have been contacted but found no documentation to support that this had been done. This failure to communicate with the legal guardian led to a complaint being filed with the State Agency, which prompted the investigation and subsequent citation.
Improper Storage of Resident Property
Penalty
Summary
The facility failed to appropriately store resident property for two residents, leading to the potential loss and/or theft of personal possessions. During a medication storage observation, an LPN was found storing a Ziplock bag containing cash and a cell phone belonging to two different residents in the narcotic drawer of a medication cart. The LPN acknowledged that resident money and personal items should not be stored in the medication cart and was unclear about the facility's policy for personal property storage. The ADON confirmed that residents' money should be stored in the business office and that personal property should never be stored in a medication cart. Despite this, the LPN placed the items back into the cart after the observation. A request for the facility's policy on personal belonging storage was made but not received by the end of the survey.
Failure to Prevent and Timely Identify Pressure Ulcers
Penalty
Summary
The facility failed to implement preventative interventions and timely assess and identify the formation of pressure ulcers for one resident, resulting in the resident acquiring one Stage 2 and two Stage 3 pressure ulcers. The resident, who was admitted with severe cognitive impairment and was dependent on staff for all activities of daily living, was observed with dressings on both ears. The clinical record revealed that the resident developed a Stage 3 pressure ulcer on the left ear and right shoulder, and a Stage 2 pressure ulcer on the right ear while in the facility. The facility's interventions included administering treatment per physician orders and using a low air loss mattress and positioning devices, but no other interventions were initiated before the development of the Stage 3 pressure ulcers. The facility's staff, including the Wound Care Manager and Nurse Practitioner, confirmed the presence of the pressure ulcers. The Assistant Director of Nursing, serving as the Acting Director of Nursing, acknowledged that staff should identify skin concerns before they progress to Stage 3. The facility's policy on skin and wound care required routine body audits by licensed nurses and nursing assistants, with immediate reporting of any new skin breakdowns. However, the policy was not effectively implemented, leading to the resident's pressure ulcers being identified only at advanced stages.
Failure to Ensure Proper Vaccine Consent and Administration
Penalty
Summary
The facility failed to ensure vaccine consent/declination was signed by a resident's legal guardian and did not accurately track and administer pneumococcal vaccinations for three residents. One resident, who had a legal guardian, had their influenza vaccine refusal documented as if they had made the decision themselves, without the legal guardian's consent. Another resident had received a Pneumovax 23 vaccine in 2017 but was due for a PCV15 or PCV20 vaccine according to CDC guidelines, which had not been administered. A third resident was also due for a PCV15 or PCV20 vaccine, but this had not been given either. The Assistant Director of Nursing (ADON) confirmed that any consent should always be signed or declined by the legal guardian and had no explanation for why the pneumococcal vaccines had not been administered as recommended by CDC guidelines. The facility's policies on influenza and pneumococcal vaccinations were reviewed and found to be in place, but not followed correctly. The influenza vaccination policy required informed consent from the resident or their legal representative, which was not obtained in the case of the resident with a legal guardian. The pneumococcal vaccination policy required offering the vaccine unless medically contraindicated or already immunized, and to follow CDC guidelines for the type of vaccine, which was not adhered to for the two residents who were due for the PCV15 or PCV20 vaccines. The ADON, who also served as the Infection Control Nurse, was unable to provide a reason for these lapses in vaccine administration and consent documentation.
Failure to Protect Resident from Physical Restraints and Mistreatment
Penalty
Summary
The facility failed to protect a resident's right to be free from physical restraints and mistreatment during care, resulting in a fracture of the fourth digit on the resident's right hand. The resident, who has severe cognitive impairment and requires assistance for all activities of daily living, reported that a male staff member pressed on his right hand, causing the injury. The resident's hand was observed to be swollen and discolored, and an X-ray confirmed the fracture. Despite the resident's consistent statements identifying the perpetrator, the facility's investigation was inconclusive, and the alleged perpetrator was only suspended pending further investigation. The incident report and medical records revealed that the resident's hand injury was first noticed by a CNA, who reported it to the nurse. The facility's investigation included interviews with staff and the resident, with the resident consistently describing the perpetrator as a male staff member who had hurt him before. However, the facility's investigation did not substantiate the abuse allegation, citing the resident's comorbidities and the possibility of the injury occurring during care when the resident was combative. Interviews with other staff members indicated that the alleged perpetrator had a history of aggressive behavior towards both residents and staff. One CNA reported feeling uncomfortable and scared around the alleged perpetrator due to his aggressive tone. Despite these reports, the facility's investigation did not result in any definitive action against the alleged perpetrator, and the facility's administration was unsure of how the injury occurred. The facility's policy on abuse emphasizes the residents' right to be free from mistreatment, but the investigation and response to this incident were inadequate in ensuring this right.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
