Hazel I Findlay Country Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Saint Johns, Michigan.
- Location
- 1101 S Scott Road, Saint Johns, Michigan 48879
- CMS Provider Number
- 235602
- Inspections on file
- 17
- Latest survey
- September 15, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Hazel I Findlay Country Manor during CMS and state inspections, most recent first.
Surveyors found that food service equipment and kitchen areas were not effectively cleaned or maintained, with persistent ice buildup, soiled sinks and vents, lime scale, food debris, and grease accumulation observed during multiple inspections. These unsanitary conditions affected 99 residents.
The facility did not follow its own abuse and neglect policies for two residents who reported rough or rude treatment by staff and a roommate. In both cases, the administrator did not conduct a thorough investigation or report the allegations to the state agency, and documentation was incomplete, failing to meet the facility's written protocols.
The facility did not report allegations of abuse involving two residents to the State Agency, despite being aware of incidents such as verbal altercations, staff rudeness, and rough handling during care. The administrator determined these incidents were not reportable and only minimal internal documentation and follow-up were completed, with no thorough investigation or external reporting.
Two residents reported incidents involving staff rudeness, rough handling, and verbal altercations, but the facility failed to conduct thorough investigations or maintain adequate documentation. The administrator determined these incidents did not meet abuse criteria and did not report them, resulting in insufficient follow-up and lack of comprehensive inquiry.
An LPN documented the administration of medications for a resident with multiple health conditions before the medications were actually given. The resident initially declined the medications, which were then labeled and stored in the medication cart. The LPN left the cart unlocked and unattended while preparing another resident's medication, and later administered the medications to the resident. The MAR showed the medications as given before actual administration, contrary to facility policy and professional standards.
A resident with neuropathy and other chronic conditions experienced unnecessary pain when staff failed to continue administering Neurontin as ordered by the provider. The medication, which had been effective in managing the resident's pain, was stopped without family notification, and there was a delay of several days before the provider's order to resume the medication was implemented.
A deficiency was cited when a resident’s drug regimen included unnecessary medications, either lacking clinical indication, being excessive in duration, or duplicative, without proper documentation to justify their use.
An LPN prepared a resident's medication in advance, placed it in a labeled cup, and stored it in an unlocked medication cart after the resident declined to take it immediately. The LPN then left the cart unattended and unlocked while assisting another resident, contrary to professional standards requiring medication carts to be locked and medications not to be pre-poured and stored for later use.
A resident with dementia and anxiety was prescribed hydroxyzine, a high-risk medication for older adults. Despite a pharmacist's recommendation to discontinue it, the medication was not stopped, and the resident continued receiving it for months. The facility staff could not explain the discrepancy, and a gradual dose reduction was eventually ordered following an Interdisciplinary Team meeting.
A facility failed to conduct timely laboratory testing for a resident on psychotropic medication, as required by Physician's Orders. The resident, with diagnoses including severe vascular dementia and moderate cognitive impairment, was supposed to have a Hemoglobin A1C and Lipid Panel drawn every six months. Despite recommendations to continue Zyprexa and perform these tests, the last tests were conducted over a year ago. The DON confirmed the lapse in testing for antipsychotic medication monitoring.
A resident's medical records were found to be incomplete due to documentation errors in the monthly medication regimen reviews (MRR). Despite recommendations made in February to adjust medications, the MRR forms incorrectly indicated no recommendations. The Director of Nursing acknowledged the oversight, noting that the pharmacist responsible for the MRR had documented incorrectly.
Failure to Maintain Clean and Sanitary Food Service Equipment and Environment
Penalty
Summary
Surveyors observed multiple failures in the facility's food service area regarding the cleaning and maintenance of equipment and surfaces. During initial and follow-up tours, the main freezer was found to have ice accumulation on the floor, and the walk-in cooler had food debris on the floor. The dishwasher exhibited lime scale and red deposits both inside and outside, with the surrounding floor also visibly soiled. Several hand sinks and faucets throughout the kitchen were stained and covered with lime deposits, and the toaster on the tray line had visible breadcrumbs on all sides. Oven racks were soiled with layers of burnt residue, and old grease and dust were present on top of the oven. Dust and cobwebs were noted on the sprinkler system above the stove, and the vent hood above the stove was covered with old grease. Additionally, five air vents in the kitchen ceiling and the surrounding ceiling tiles were observed to be soiled. These deficiencies were present during both the initial and follow-up inspections, indicating a lack of effective cleaning and maintenance practices. The issues affected the food service environment for 99 residents, as the unsanitary conditions persisted over multiple days and were not addressed between surveyor visits.
Failure to Implement Abuse and Neglect Policies and Procedures
Penalty
Summary
The facility failed to implement its own written policies and procedures for abuse and neglect prevention for two residents. One resident reported waiting two hours for assistance, after which a staff member entered her room, acted disgusted, and provided care in a rough manner, causing the resident pain and distress. Documentation showed that the incident was not thoroughly investigated, as required by facility policy. There was no evidence of interviews with the resident or staff, nor was the incident reported to the state agency, despite the policy stating that any suspicion or allegation of abuse warrants immediate investigation and reporting. Another resident, with moderate cognitive impairment and multiple medical diagnoses, reported that a staff member was rude to her and also described a verbal altercation with a roommate that made her feel unsafe. The facility's documentation of these incidents was minimal, with only brief notes indicating that the resident was moved or that the staff member received verbal education. There was no evidence of a comprehensive investigation, interviews with involved parties, or reporting to the state agency as outlined in the facility's abuse and neglect protocol. In both cases, the administrator determined that the incidents did not meet the criteria for abuse and therefore did not initiate a full investigation or report the allegations. The facility's actions did not align with its own policies, which require thorough investigation and timely reporting of all allegations or suspicions of abuse, neglect, or exploitation. The lack of proper documentation and follow-up demonstrates a failure to protect residents and ensure compliance with regulatory requirements.
Failure to Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency for two residents, despite being aware of the incidents. One resident, who had Huntington’s Disease and moderate cognitive impairment, reported that a staff member was rude to her and also described a verbal altercation with a roommate, expressing that she did not feel safe. These concerns were documented in facility grievance forms, and immediate actions such as moving the roommate were taken. However, the Nursing Home Administrator, who served as the abuse coordinator, determined that these incidents did not meet the criteria for abuse and did not report them to the state. Documentation provided for these events was minimal, with no thorough investigation records available beyond brief notes indicating the incidents were considered non-reportable and that no harm or distress was observed. Another resident reported waiting two hours for assistance and described being handled roughly by a staff member, which caused her pain. This concern was documented in a grievance form and a non-reportable allegation form, with a nursing assessment performed that found no new information or injury. The administrator and DON interviewed the resident, who stated she was in pain but could not identify the staff member involved. The administrator concluded that the incident was related to the resident’s underlying pain rather than staff mistreatment, and therefore did not report the allegation to the state agency. In both cases, the facility’s actions were limited to internal documentation and brief follow-up, without conducting or documenting thorough investigations or reporting the allegations to the appropriate authorities as required. The decision not to report was based on the administrator’s judgment that the incidents did not meet the threshold for abuse, despite the residents’ statements and the facility’s own documentation of their concerns.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of abuse for two residents out of four reviewed. One resident with Huntington’s Disease and moderate cognitive impairment reported that a staff member was rude to her, and also reported a verbal altercation with a roommate that made her feel unsafe. Documentation showed that the facility moved the roommate temporarily and provided verbal education to staff, but there was no evidence of a thorough investigation or interviews with the resident regarding the acceptability of the solutions. The facility administrator, who also served as the abuse coordinator, determined these incidents did not meet the criteria for abuse and did not report them to state agencies, nor did she maintain comprehensive investigation files beyond brief notes indicating no harm or distress. Another resident reported waiting two hours for assistance, after which a staff member allegedly acted disgusted, turned her roughly, and told her to stop yelling despite her pain. The concern was documented, and a nursing assessment was performed, but there was no documentation of a thorough investigation, interviews with the resident about the acceptability of the solution, or interviews with other staff or residents. The administrator concluded the incident was related to the resident’s pain and did not identify it as an abuse allegation, documenting only a brief summary on a non-reportable allegation form. In both cases, the facility did not conduct comprehensive investigations into the allegations of abuse or mistreatment, did not interview all relevant parties, and did not maintain adequate documentation of their investigative process. The administrator relied on her own judgment to determine that the incidents did not constitute abuse, resulting in a lack of proper reporting and investigation as required.
Failure to Follow Professional Standards for Medication Documentation
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow professional standards for medication documentation for a resident with multiple complex medical conditions, including aortic valve stenosis, congestive heart failure, diabetes, and vascular dementia. During a medication pass, the LPN prepared the resident's medications and documented their administration in the Medication Administration Record (MAR) before the resident actually received them. The resident initially refused to take the medications until after using the bathroom, prompting the LPN to label the medication cup and store it in the medication cart. The LPN then left the medication cart unlocked and unattended while preparing another resident's medication, only returning to lock it a few minutes later. The resident eventually took the medication after notifying the LPN that she was ready. However, the MAR reflected that the medications had been administered at an earlier time, prior to actual administration. Facility policy and the Director of Nursing's expectations require that medication administration be documented only after the medication has been given to the resident. The LPN's actions did not align with these standards, resulting in inaccurate documentation of medication administration.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to follow provider orders for a resident with multiple diagnoses, including congestive heart failure, COPD, muscle weakness, and neuropathy. The resident had impaired mobility and was dependent on staff for most activities of daily living. The resident had been prescribed Neurontin 100 mg capsules for neuropathy pain, which was reported by the family to be effective in managing the resident's burning and pain. However, the medication was stopped without discussion with the family, and the resident's pain returned. The family brought the issue to the attention of staff after noticing the resident's increased pain. Review of the medication administration records and interviews revealed that the provider had ordered Neurontin 100 mg three times daily after a two-week evaluation period, and this order was documented as received by the facility. Despite this, the medication was not administered from the date the order was received until several days later. Staff were unable to explain how the order was missed during this period, resulting in the resident experiencing unnecessary pain due to the lapse in medication administration.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated, excessive in duration, or duplicative, without adequate justification documented in the medical record.
Medication Security and Storage Deficiency
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) prepared a resident's medication by placing multiple prescribed drugs into a medication cup and labeling it with the resident's name. The LPN placed the cup in the top drawer of the medication cart after the resident declined to take the medication immediately, stating she wanted to use the bathroom first. The LPN then left the medication cart unlocked and unattended while preparing and administering medication to another resident. The cart remained unlocked and unattended for several minutes before the LPN returned and locked it. The resident involved had a complex medical history, including aortic valve stenosis, muscle weakness, dysphagia, congestive heart failure, diabetes, and other chronic conditions. The Director of Nursing (DON) confirmed that professional practice requires medication carts to be locked when not in use or not under direct supervision by a licensed nurse, and that medications should not be pre-poured and stored in the cart for later administration. The observed actions did not comply with professional standards for medication security and storage.
Failure to Discontinue High-Risk Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. The resident, who had diagnoses including dementia, anxiety, and major depressive disorder, was prescribed hydroxyzine, an antihistamine with strong anticholinergic properties, for anxiety and sleep issues. Despite a pharmacist's recommendation to discontinue the medication due to its high-risk nature for older adults, the medication was not discontinued as per the recommendation. The physician's response indicated the medication was discontinued, but the resident continued to receive it until a gradual dose reduction was ordered months later. The resident was observed to be tired and reported not usually napping unless unwell, suggesting potential effects of the medication. Interviews with the Director of Nursing and House Supervisor revealed they could not explain why the medication was not discontinued as recommended by the pharmacy. The gradual dose reduction was noted to be in response to an Interdisciplinary Team meeting rather than the pharmacy's recommendation, indicating a lack of communication and follow-through on the pharmacist's advice.
Failure to Conduct Timely Laboratory Monitoring for Psychotropic Medication
Penalty
Summary
The facility failed to ensure laboratory testing for psychotropic medication monitoring was completed according to Physician's Orders for a resident. The resident, who was admitted and readmitted with diagnoses including congestive heart failure, obsessive-compulsive disorder, and severe vascular dementia with psychotic disturbance, was observed to have moderate cognitive impairment. A Physician's Order dated June 30, 2023, required a Hemoglobin A1C and Lipid Panel to be drawn every six months. Additionally, a psychiatric visit note from May 10, 2024, recommended continuing Zyprexa and conducting these tests every six months. However, the resident's medical record indicated that the last Hemoglobin A1C and Lipid Profile were drawn in July 2023, indicating a failure to perform the required tests within the specified timeframe. The Director of Nursing confirmed that the purpose of the laboratory monitoring was for antipsychotic medication use and acknowledged the lapse in testing.
Incomplete Medical Records Due to Documentation Errors
Penalty
Summary
The facility failed to accurately document in the medical record for one resident, resulting in incomplete medical records. The resident, who was admitted with diagnoses including unspecified dementia, moderate intellectual disability, and anxiety disorder, had a severe cognitive impairment score on the Brief Interview for Mental Status. The resident's medical records showed monthly medication regimen reviews (MRR) with no recommendations for several months. However, the MRR for February contained recommendations that were not accurately documented, leading to discrepancies in the medical records. The February MRR included recommendations to increase Donepezil dosage and re-evaluate the need for Omeprazole, which were discussed in an interdisciplinary team meeting. Despite these recommendations, the monthly MRR form was incorrectly completed, indicating no recommendations were made. The Director of Nursing (DON) acknowledged the oversight and mentioned that the Assistant Director of Nursing (ADON) tracks recommendations after they are returned with the provider's signature. The DON also noted that the pharmacist responsible for the MRR had documented incorrectly, contributing to the incomplete records.
Latest citations in Michigan
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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