Healthsource Saginaw, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Saginaw, Michigan.
- Location
- 3340 Hospital Rd, Saginaw, Michigan 48603
- CMS Provider Number
- 235150
- Inspections on file
- 37
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Healthsource Saginaw, Inc during CMS and state inspections, most recent first.
A resident receiving therapy after a hip fracture reported that an unfamiliar LPN entered his room, did not verify his identity, and administered a handful of pills, a chocolate nutritional drink, and a nasal spray, despite the resident stating he did not receive a nasal spray and did not like chocolate drinks. The LPN was working an extra shift on an unfamiliar unit and later admitted she confused two side-by-side rooms occupied by residents with the same first name, giving one resident another resident’s BP and cardiac medications and intended IV antibiotic dose. The resident subsequently felt markedly “high” and informed staff and family, and review of records showed limited vital sign monitoring documented around the time of the error.
A cognitively impaired resident with Alzheimer’s, dementia, psychotic disturbances, and a history of agitation had an active care plan requiring 1:1 staff supervision for safety, but this intervention was not implemented. The resident, who required assistance with all ADLs, entered the adjacent room of another cognitively impaired resident with multiple neuropsychiatric diagnoses and agitation. Video showed a CNA seated in the hallway near both rooms using a personal cell phone while the first resident went unaccompanied into the second resident’s room, leading to the second resident yelling and being scratched in the face.
Two residents with the same first name were involved in a medication error when an LPN, working an unfamiliar assignment, entered the wrong room and administered a handful of oral medications, a chocolate nutritional supplement, and a nasal spray without using two identifiers or noting the absence of an ID bracelet. A cognitively intact resident with chronic kidney disease and recent hip fracture received another resident’s regimen, including Eliquis, Entresto, Jardiance, Lopressor, and spironolactone, in addition to his own scheduled medications, and later reported feeling lightheaded and "high." The intended recipient, a medically complex resident on IV Vancomycin with multiple cardiac and infectious diagnoses and DNR status, did not receive his prescribed doses. The facility’s policies required two-identifier verification and prohibited administering one resident’s medications to another, and its occurrence reporting policy required prompt reporting and investigation of medication-related incidents, but leadership became aware of the possible error only later in the day after staff notification.
The facility did not consistently implement fall prevention interventions as outlined in the care plans for two residents at risk for falls. Observations showed that required safety equipment, such as floor mats and accessible call lights, were not in place or within reach, and staff interviews confirmed these lapses. Both residents had recent falls, and the facility's protocols for individualized fall prevention were not followed.
A resident with a history of aphasia and cerebral infarction was found on the floor after an unwitnessed fall. A CNA observed the resident but left to attend to another upset resident, closing the door to the room. The resident's son later found his mother on the floor and became angry. Interviews revealed a lack of immediate assistance and communication among staff, contributing to the deficiency in care.
A resident with a history of falls and on anticoagulants experienced two falls shortly after admission to an LTC facility. Despite being identified as a high fall risk, the resident was inadequately supervised, leading to a fatal head injury. Staff interviews revealed communication gaps and insufficient monitoring, contributing to the incident.
A resident with multiple medical conditions developed a pressure ulcer that worsened over time due to the facility's failure to provide timely treatment and communicate with the physician. Despite signs of infection and deterioration, the facility did not initiate antibiotic treatment or report the condition to the physician, resulting in the resident developing sepsis and requiring hospital admission.
Two residents developed pressure ulcers due to inadequate preventive measures. One resident's ulcer was caused by bedding friction, and no pressure-relieving devices were used. Another resident's ulcer resulted from an AFO brace, with no initial order to monitor the skin. The facility failed to adhere to its pressure ulcer prevention policy.
The facility failed to make previous survey results and contact information for the State Hotline and Ombudsman accessible to all residents. The survey results binder was located in the front lobby, which was not easily accessible to all residents, especially those unable to travel the distance from the 500 hallway/nursing unit. Additionally, the contact information was placed at a height and in a format not accessible to residents in wheelchairs, leading to complaints during a Resident Council meeting.
The facility did not ensure that the daily staff posting was accessible to all residents, as it was only available at the front desk, located 580 feet from the main corridor of the 500 nursing unit. The DON confirmed that there were no individual postings for each nursing unit. Central Staffing emailed the staff posting to the switchboard operator, who printed it and placed it in a plastic file folder on the front counter, without posting it elsewhere.
The facility's kitchen, serving 162 residents, was found unsanitary with several deficiencies. Observations included a trash bin without a lid next to the grill, a microwave with dried food particles, and a can opener with dried food and chipping paint. Food items like shrimp, crackers, roast beef, and jelly lacked dates, and the brown sugar was expired. The facility failed to comply with its Food Storage policy and the 2017 FDA Food Code.
The facility failed to ensure a clean and safe environment across multiple units, with issues such as dirty CPAP machines, undated food items, and improper storage of medical equipment. Observations revealed dirty floors, incomplete temperature logs, and improper storage of personal items. The Director of Nursing and Director of Maintenance acknowledged these deficiencies, indicating a lapse in maintaining sanitary conditions as outlined in the facility's environmental services job description.
The facility failed to address resident grievances and did not invite all residents to the Resident Council meeting, leading to feelings of exclusion and frustration. Residents reported issues with staff behavior, including loudness, rude call light responses, and inadequate care. A Resident Council member felt deliberately excluded from a meeting with the state. The facility's records showed that several complaints were not documented or addressed, and the Director of Nursing was unaware of who was responsible for grievance follow-up.
The facility failed to provide a clean and homelike environment, with surveyors observing unclean conditions, improper storage of soiled clothes, and pest infestations in various areas. Residents expressed dissatisfaction with the use of plastic silverware and lack of condiments during meals. Staff acknowledged these issues, but immediate corrective actions were not evident.
The facility failed to provide adequate ADL care for several residents, resulting in hygiene issues such as long, dirty nails, unshaved facial hair, and unbrushed teeth. One resident reported delayed assistance with toileting, while another had severe cognitive deficits and was not receiving oral care despite having supplies. These deficiencies indicate a lack of adherence to care plans and responsibilities by CNAs.
The facility failed to honor the food preferences of four residents, leading to dissatisfaction and potential nutritional issues. One resident expressed dissatisfaction with the facility's food, citing issues such as excessive pepper and overcooked zucchini. Another resident reported not receiving cereal, which was a regular part of his diet, and being served fish despite having a seafood allergy. A third resident complained about overly spicy food and inadequate breakfast options, while a fourth resident expressed dissatisfaction with the food, opting for snacks or meals brought by family instead. The facility's policy on food and nutrition services aims to provide appropriate, attractive, and palatable food, but the residents' experiences indicate a failure to meet these standards.
The facility failed to provide adequate snacks for residents, leading to complaints about limited availability and variety. Residents, including diabetics, expressed frustration over the lack of healthy snack options and reliance on family for snacks. Observations confirmed minimal snack availability, with limited options like turkey sandwiches and a lack of fresh fruit.
The facility failed to follow infection control standards, with staff not adhering to proper PPE use, hand hygiene, and linen transport protocols. Observations included staff assisting residents without changing gloves or performing hand hygiene, and carrying clean linen against uniforms without barriers, increasing the risk of infection spread.
The facility failed to maintain resident dignity and privacy, as evidenced by inadequate privacy measures for a resident and delays in assistance. Residents reported dissatisfaction with delayed responses to call lights and inadequate grooming, leading to feelings of neglect and disrespect. Observations and interviews highlighted these deficiencies, with residents expressing frustration over the lack of timely and polite assistance.
The facility failed to incorporate PASARR Level II recommendations for specialized mental health services into the care plans of two residents with mental illness diagnoses. Despite having full cognitive abilities and requiring assistance with all care, the residents' care plans lacked any mention of specialized services. Interviews revealed a lack of communication with the Community Mental Health agency, and the facility's policy on coordinating assessments with the PASARR program was not followed.
The facility failed to update care plans for residents with complex needs, including a resident with multiple pressure ulcers and another with a history of falls and wandering. The care plans were outdated and lacked specific interventions, posing a risk of unmet care needs.
A resident with diabetes and other medical conditions experienced multiple episodes of low blood sugar, leading to hospitalization. The facility failed to monitor blood glucose levels properly and continued to administer insulin without notifying the physician, despite dangerously low readings. The care plan's instructions for managing diabetes were not consistently followed, contributing to the resident's deteriorating condition.
A facility failed to manage and monitor a resident's left arm splint, resulting in the resident having a soiled splint that had not been laundered. The resident, with a history of stroke and left-sided weakness, wore the splint at night. The Restorative Nurse noted that the splint was initially worn all the time but later changed to nighttime use. There was no clear responsibility for cleaning the splint, and a policy for hand splints was not provided. The care plan included assistive devices and skin checks but lacked details on splint usage and cleaning.
A resident with severe cognitive impairment and a history of combativeness sustained a laceration to the left eyebrow during a transfer using a Sara lift. The resident, who required assistance with all ADLs, exhibited aggressive behaviors earlier in the day. Despite this, the transfer was conducted by a single CENA, contrary to the care plan which did not specify the use of a mechanical lift.
A resident experienced significant weight loss due to the facility's failure to document food intake, provide suitable utensils, and notify the physician. The resident struggled with meal consumption due to impaired cognition and inadequate assistance, leading to numerous undocumented meals. Despite increased nutritional supplements, there was insufficient documentation of snack provision, and the physician was not informed of the weight loss.
The facility failed to properly clean, sanitize, and store respiratory equipment for residents, leading to potential cross-contamination and respiratory issues. A resident's CPAP machine was found dirty and not stored correctly, while another resident's oxygen concentrator was alarming with tubing on the floor, not supplying oxygen. Additionally, a third resident was observed with oxygen tubing in place, but the concentrator was not turned on, and the tubing was not dated as required by facility policy.
A resident with end-stage renal disease and dependence on dialysis was not properly monitored for changes at the dialysis port site, leading to the initiation of antibiotics due to drainage. The facility lacked a policy for assessing and monitoring dialysis ports, and staff confirmed that dressings were changed weekly or as needed. An order to monitor the port site was only established after the issue was identified.
A survey found that three medication carts in the facility were not properly cleaned, with crushed pills, paper, and dust present in the drawers. Interviews with nursing staff revealed confusion over cleaning responsibilities, with the DON indicating that second shift nurses were responsible. This lack of clarity contributed to the unsanitary conditions observed.
The facility failed to document the reason for antibiotic use and track antibiotic use for two residents, leading to potential inappropriate use. One resident was prescribed Doxycycline without a documented diagnosis, and another was given Bactrim for prophylaxis without a clear reason. The Infection Prevention and Control Nurse noted that the electronic medical record system did not allow for adding diagnoses with orders, and the facility's Antibiotic Stewardship policy was not effectively implemented.
A resident fell in the bathroom, sustaining facial fractures and subacute bilateral subdural hematomas. The facility failed to complete a comprehensive fall investigation, notify the physician of X-ray results, and provide timely medical intervention, leading to a significant delay in treatment.
Wrong-Medication Administration to Resident With Same First Name
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to adequate care and treatment during medication administration, resulting in the resident receiving another resident’s medications. The resident, who was in the facility for therapy after falling in his kitchen and cracking his hip, reported that a nurse who was not his regular nurse entered his room in the morning and gave him a handful of 4–5 pills, including a blue pill, along with a chocolate nutritional drink and a nasal spray. The resident stated the nurse did not ask his name, he had no ID bracelet on, and he told the nurse he did not receive a nasal spray and did not like chocolate nutritional drinks. He also reported that the nurse appeared to be looking for an IV port and IV equipment in his room, which he did not have, while a male resident in the next room with the same first name did have an IV pole. The resident later went to therapy, where his regular nurse brought his usual medications, prompting him to realize he had received extra medications earlier. He reported feeling lightheaded and “high,” describing the sensation as if he had smoked multiple marijuana cigarettes, and his brother, who was with him, commented that he looked high. The resident stated he informed staff, but he did not recall all details because he felt “out of it.” The facility’s investigative report documented that the family raised concerns about a medication error, and that the resident reported receiving medications from one nurse and then again from another nurse that same morning, both calling him by his first name, though he only recognized his regular nurse. In a subsequent interview, the LPN who passed the wrong medications explained she had picked up an extra shift on a unit where she did not usually work and was assigned a specific medication cart and room range. She stated that two residents with the same first name were in side-by-side rooms and that she mistakenly administered medications intended for one resident, including an IV antibiotic order, to the other resident. She acknowledged that she went to the wrong room and gave the wrong medications to the wrong resident, and that the other resident did not receive those medications. Vital sign records for the affected resident showed documentation at 1:37 a.m. and then not again until early evening that day, with no vital signs recorded around the time of the morning medication error.
Failure to Implement One-on-One Supervision Care Plan Resulting in Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement an active care plan intervention for one-on-one supervision for a cognitively impaired resident with a history of agitation and behavioral issues. Resident #103, a 79-year-old with Alzheimer’s, dementia, psychotic disturbances, agitation, and depression, had a BIMS score of 3 and required staff assistance with all ADLs. The resident’s behavioral care plan, dated 10/21/25, specified that the resident would have 1:1 staff supervision for safety, and this intervention had not been discontinued at the time of the incident. On the date of the incident, video review showed that Resident #103 left her room and entered the adjacent room of Resident #106 without being accompanied by staff, despite the active 1:1 supervision care plan. Resident #106, an 82-year-old with Alzheimer’s, dementia, Parkinson’s, schizophrenia, bipolar disorder, stroke, and agitation, also had a BIMS score of 3 and required assistance with all ADLs. According to the incident report, when Resident #103 entered Resident #106’s room, Resident #106 yelled for her to get out, and Resident #103 scratched him in the face. Video observation showed CNA C seated in the hallway next to both residents’ rooms, using her personal cell phone to text and scroll, with a portable computer positioned in a way that blocked her from the view of the nursing station. During this time, Resident #103 went into Resident #106’s room without intervention from CNA C. Interviews confirmed that Resident #103 was care planned for 1:1 supervision for safety at the time and that this intervention remained active and had not been discontinued, yet it was not being implemented when the resident-to-resident interaction and resulting scratches occurred.
Wrong-Resident Medication Administration Due to Failure to Verify Identity
Penalty
Summary
The deficiency involves the facility’s failure to prevent significant medication errors when an LPN administered a set of medications intended for one resident to another resident with the same first name. The facility’s own "Medication Administration General Guidelines" policy required that residents be identified using a minimum of two identifiers before medication administration and that medications supplied for a specific resident not be administered to others. During the incident, the nurse did not verify the resident’s identity with two identifiers, and the resident who received the wrong medications did not have an ID bracelet on his arm at the time. The nurse entered the wrong room and provided a handful of 4–5 pills, a chocolate nutritional supplement, and a nasal spray to the resident, who reported that he does not receive a nasal spray and does not like chocolate supplements. The resident who received the wrong medications (Resident #101) had been admitted with diagnoses including prosthetic left hip joint fracture, nondisplaced subtrochanteric fracture of the left femur, abnormal gait and mobility, chronic kidney disease, benign prostatic hyperplasia, and asthma. His MDS showed he was cognitively intact with a BIMs score of 15/15, and his advance directives indicated full code status. After receiving the medications, he reported feeling lightheaded and "high," describing feeling as if he had smoked multiple marijuana cigarettes, and stated he did not recall everything that happened because he was "out of it." He later informed staff that he believed he had received extra medications that morning. Vital sign documentation for him on the day of the incident showed a blood pressure of 113/70, pulse 95, and respirations 19 in the early morning, with no further vital signs recorded until the evening. The medications administered in error to Resident #101 were identified through pharmacy review as Eliquis 5 mg (anticoagulant), Entresto 24-26 mg (antihypertensive cleared through kidneys), Jardiance 10 mg (for diabetes/heart failure, cleared through kidneys), Lopressor 50 mg (beta blocker antihypertensive), and Spironolactone 25 mg (diuretic antihypertensive cleared through kidneys). These medications belonged to another resident (Resident #102), who had multiple serious medical diagnoses including MRSA, sepsis, bacteremia, pneumonia, long-term IV Vancomycin therapy, embolism and thrombosis, cardiomyopathy, left bundle branch block, tachycardia, heart failure, hypertension, hyponatremia, dysphagia, autistic disorder, epilepsy, anemia, and anxiety disorder, and whose advance directives indicated DNR status. The LPN involved acknowledged in interview that she made a mistake by giving the wrong medications to the wrong resident with the same first name and stated that the other resident did not receive his medications. The pharmacist, when asked if this constituted a significant medication error, stated it was a subjective, simple mistake and noted that resident rights of medication administration are a nursing issue at the point of administration. The facility’s occurrence reporting policy required reporting and investigation of medication-related incidents and harmful unintended results caused by taking medications, but the report documents that the ADON became aware of the possible medication error only later that evening after staff notification.
Failure to Implement Fall Prevention Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for fall safety prevention for two residents identified as being at risk for falls, accidents, and hazards. For one resident, who had a history of falls, dementia, and was receiving hospice care, the care plan required a blue floor mat to be placed next to the bed in the low position. However, multiple observations throughout the day revealed that the floor mat was not in place as required, instead being found leaning against the wall at the end of the bed. There was also no physician's order for a floor mat, despite the care plan directive. The Director of Nursing confirmed that the floor mat should have been in place according to the care plan. For another resident with severe cognitive impairment, Alzheimer's disease, and recent decline on hospice care, the care plan required the call light to be within reach at all times and a floor mat to be placed next to the bed. Observations over several days showed the call light was consistently coiled around the grab bar, out of the resident's reach, and the resident reported calling out for help instead of using the call light. The floor mat was also found folded and pushed away from the bed on one occasion. Staff interviews confirmed that the call light and floor mat were not positioned as required by the care plan, and that residents with limited ability to use call lights should be monitored more frequently. Record reviews indicated both residents had recent falls, and the facility's fall prevention program required individualized interventions to be implemented and monitored for effectiveness. Despite these protocols, the care plan interventions for fall prevention were not consistently followed, as evidenced by the observations and staff interviews.
Inadequate Post-Fall Assistance for Resident
Penalty
Summary
The facility failed to provide adequate post-fall assistance to a resident, resulting in feelings of sadness and tearfulness. The resident, who is non-verbal and has a history of aphasia, cerebral infarction, anxiety, and depression, was found sitting on a floor mat next to the bed after an unwitnessed fall. The incident occurred when a CNA observed the resident on the floor but chose to attend to another resident across the hall who was upset, leaving the resident unattended. The CNA closed the door to the resident's room to diffuse the situation between the resident and the other upset resident, which led to the resident's son entering the room and becoming angry upon finding his mother on the floor. Interviews with staff revealed that the LPN was in a nearby room and was alerted by yelling, while the CNA who initially found the resident on the floor did not stay with the resident or seek immediate help. Another CNA, who was the primary caregiver, was under the impression that the first CNA would stay with the resident. The Director of Nursing stated that the expectation is for staff to call for help and leave the resident in the position they were found until a nurse arrives. The lack of immediate assistance and communication among staff contributed to the deficiency in care provided to the resident after the fall.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to adequately supervise and prevent a fall for a resident with a known history of falls and anticoagulant use, resulting in a fatal incident. The resident, who was admitted to the facility from an assisted living environment, had a documented history of falls and was on medications with blood-thinning effects, such as Plavix and aspirin. Upon admission, the resident was assessed as a high fall risk due to factors including confusion, impulsivity, and the need for assistance with mobility. On the day of admission, the resident experienced two falls within a short period. The first fall occurred when the resident attempted to pick up spilled items from the floor, resulting in no visible injury. Despite being identified as a high fall risk, the resident was placed in a wheelchair and moved to the dining/day room due to restlessness. The second fall happened in this area, where the resident fell from the wheelchair, sustaining a significant head injury, including a large hematoma and bleeding. The staff's response to the resident's condition was inadequate, as there was a lack of consistent monitoring and documentation of neuro checks following the falls. The resident's condition deteriorated, leading to hospitalization and subsequent death due to complications from the head injury. Interviews with staff revealed a lack of clear communication and understanding of the resident's needs, contributing to the failure to prevent the falls and provide appropriate supervision.
Failure to Provide Timely Treatment for Pressure Ulcer
Penalty
Summary
The facility failed to provide timely treatment and care for a resident with a pressure ulcer, leading to severe complications. The resident, who had multiple medical conditions including diabetes, a history of stroke, and a tracheostomy, developed a pressure ulcer on the coccyx that worsened over time. Despite being at high risk for pressure ulcers, the facility did not adequately monitor or report the deterioration of the wound to the physician, resulting in the resident developing sepsis and requiring hospital admission. The facility's records indicate that the resident's pressure ulcer was first identified as a stage II wound, which later became unstageable with necrotic tissue and slough. Nursing notes documented the worsening condition of the wound, including increased size, foul odor, and bleeding, yet there was no evidence of timely communication with the physician or initiation of antibiotic treatment. The resident's condition continued to decline, with signs of infection such as fever and elevated heart rate, until they were eventually transferred to the hospital. Interviews with facility staff revealed a lack of appropriate action and communication regarding the resident's condition. The RN acknowledged a delay in treatment and failure to assess the situation adequately. The Infection Control Nurse and the Wound Nurse both admitted that they did not contact the physician despite the worsening condition of the pressure ulcer. The Director of Nursing and Assistant Director of Nursing recognized the issue as a significant problem, indicating a systemic failure in the facility's response to the resident's needs.
Failure to Prevent Pressure Ulcers in Residents
Penalty
Summary
The facility failed to prevent the development of pressure ulcers in two residents, resulting in discomfort and the need for ongoing wound care. Resident #415, who was admitted with multiple health issues including dementia and chronic pain, developed a pressure ulcer on the right heel due to shearing from bedding. Despite the wound care being performed according to orders, no pressure-relieving devices were used to keep the heel off the bed, which was a contributing factor to the ulcer's development. The facility's policy required the use of such devices, but this was not adhered to, as observed during the dressing change. Resident #75, admitted with conditions such as sepsis and rheumatoid arthritis, developed a pressure ulcer on the right heel due to friction from an ankle-foot orthosis (AFO) brace. Although the resident was provided with an air mattress and pillows to elevate the feet, there was no initial physician's order to monitor the skin around the AFO. The wound care nurse confirmed that an order should have been in place upon admission, but it was only entered after the issue was highlighted during the survey. The facility's policy on pressure ulcer prevention and treatment emphasizes the need to protect against pressure, friction, and shear, and to open a care plan for residents at risk. However, the lack of timely interventions and monitoring for both residents led to the development of pressure ulcers, indicating a failure to adhere to the established standards of care.
Inaccessible Survey Results and Contact Information
Penalty
Summary
The facility failed to ensure that previous survey results, State Hotline, and Ombudsman contact information were accessible to all residents. During a Resident Council meeting, members expressed their inability to locate the survey results and contact information for the Ombudsman and State Hotline. The survey results binder was located in the front lobby, which was not easily accessible to all residents, especially those who could not travel the .11 miles/580 feet from the 500 hallway/nursing unit to the lobby. Additionally, the contact information for the State Hotline and Ombudsman was placed at a height and in a format that was not accessible to residents in wheelchairs, as it was positioned approximately 5 feet high and not in large print. Interviews with the Director of Nursing (DON) and Activity Director (AD) confirmed the location of the survey results binder and the accessibility issues. The DON stated that the binder was visible to anyone entering through the front door, but did not acknowledge the distance issue. The AD noted that some residents were independent with their wheelchairs, but did not address the accessibility for all residents. An observation with the AD revealed that the contact information was not easily visible or readable for residents in wheelchairs, further contributing to the residents' complaints about not knowing how to contact the Ombudsman or access the State Hotline number.
Inaccessible Daily Staff Posting
Penalty
Summary
The facility failed to ensure that the daily staff posting was accessible for all residents, which could lead to residents being uninformed about the available staff. On a specific day, the staff posting was located at the front desk, which was .11 miles or 580 feet away from the main corridor hallway of the 500 nursing unit. The Director of Nursing confirmed that the staff posting at the front desk was for the entire building and that individual nursing units did not have their own postings. Central Staffing personnel indicated that they fill out the staff posting and email it to the switchboard operator daily. The switchboard operator then prints the posting and places it in a plastic file folder on the front counter, without posting it elsewhere in the building.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the Arbor Cafe's kitchen, which serves a census of 162 residents. During an inspection, several deficiencies were observed, including a large trash bin without a lid next to the grill, a microwave with dried food particles, and a large can opener with dried food and chipping paint. Additionally, a clean pan was found wet inside another pan, and a large trash bin was open behind baked cookies. The freezer floor had small pieces of food and papers, and various food items in the cooler and freezer were found without dates, including shrimp, crackers, roast beef, and jelly. Further observations revealed that a large white plastic container of corn starch had an excessive amount of corn starch on top and no dates, while the brown sugar container was expired. The toaster had an excessive amount of crumbs, and a large tray of uncovered fruit with no dates was found in the back refrigerator. In the dry storage room, an opened bag of noodles was found without dates. These findings indicate a failure to adhere to the facility's Food Storage policy and the 2017 FDA Food Code, which requires equipment food-contact surfaces and utensils to be cleaned when contamination may have occurred.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment across multiple units, including Wheels, Patriot, and Garden. During an environmental tour, several deficiencies were observed, such as a dirty CPAP machine and tubing not stored properly in a clear plastic bag, and an oxygen nasal cannula found on the floor. In the day room, a water/ice machine had calcium build-up, and opened food items without dates were found in the freezer. Additionally, a resident's refrigerator contained undated and partly used ice cream. The Director of Nursing indicated that dietary staff were responsible for cleaning neighborhood refrigerators. Further observations in the Patriot Neighborhood revealed towels and razors improperly stored, a dirty shower room floor, and a fan with dust-covered blades. Undated meat, cheese, and fish were found in a resident's refrigerator, and temperature logs were incomplete. In the day room, dirty brooms and a dustpan were left near confused residents. Similar issues were noted in the Garden Neighborhood and the Activity room, where undated food items were stored in refrigerators. The Director of Maintenance acknowledged that resident room refrigerators should be checked before use, but this was not done. The facility's environmental services job description emphasized maintaining clean and sanitary facilities, which was not upheld.
Failure to Address Resident Grievances and Exclusion from Meetings
Penalty
Summary
The facility failed to ensure timely follow-up on grievances and did not invite all residents to the Resident Council meeting, leading to feelings of exclusion and frustration among residents. During a Resident Council meeting, residents expressed dissatisfaction with the facility's response to their complaints, particularly regarding staff behavior. They reported that staff were loud in the hallways, responded rudely to call lights, and often did not return after canceling them. Residents also mentioned issues such as being left in soiled conditions, being forced to go to bed early due to staffing shortages, and missing church services for the same reason. A private interview with a Resident Council member revealed that they were not informed about a meeting with the state and felt deliberately excluded. The member expressed that they were often left out of meetings and believed it was because they were vocal about their concerns. The facility's records showed that several complaints raised in Resident Council meetings over the months were not documented or addressed, including issues with staff loudness, inadequate response to call lights, and concerns about staff training and shortages. The review of grievances over the past year indicated that the most recent concern form was from May 2024, which highlighted issues with call light response times and staff friendliness. However, the facility's response did not address the call light concern adequately. When questioned, the Director of Nursing was unaware of who was responsible for following up on council grievances, indicating a lack of accountability and oversight in addressing resident concerns.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unclean and cluttered conditions in various rooms and common areas. During a tour, surveyors noted a urine-soaked wash rag on the floor, strong odors of urine, and soiled clothes improperly stored under sinks, which posed infection control issues. Additionally, several rooms had visible dirt, food debris, and residue on shower curtains and caulking, along with missing drywall and laminate chips, contributing to an unkempt environment. The presence of pests, specifically spiders and webs, was observed in multiple areas, including resident rooms, the media center, and the main dining room. These areas also had piles of dead insects, and staff acknowledged the presence of spiders. The Environmental Services Director attributed the presence of silverfish to external factors but did not address the immediate pest control needs. The Director of Nursing was informed of the pest issue but did not take immediate action to resolve it. Residents expressed dissatisfaction with the dining experience, specifically the use of plastic silverware, which hindered their ability to eat meals comfortably. During resident council meetings, complaints were made about the lack of proper silverware and condiments, with residents having to use plastic utensils to cut through tough food items. Staff confirmed these issues, and the Hospitality Director acknowledged that new silverware had been ordered but did not explain why it was not yet in use, leading to ongoing resident dissatisfaction.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for several residents, resulting in various hygiene issues. Resident #135, who is non-verbal and has dementia, was observed with facial hair and dirty nails on multiple occasions. The care plan for this resident indicated that they should receive weekly nail care and assistance with shaving, but these needs were not met. An activity aide confirmed that certified nursing assistants (CNAs) are responsible for these tasks and acknowledged ongoing issues with nail care and shaving, which had been previously reported to the infection control nurse. Resident #59, who has full cognitive abilities but requires assistance with all care, reported that her call light was not answered timely, sometimes taking up to five hours for assistance. The resident's room had a strong smell of urine, and she mentioned that her blankets were not changed frequently enough. Her care plan included interventions for urinary tract infection prevention and assistance with toileting every two hours, which were not adequately provided. Resident #117, with severe cognitive deficits, was observed with unbrushed teeth despite having supplies brought in by a family member. The care plan indicated that the resident should receive assistance with oral care, which was not being provided. Additionally, Resident #60 and Resident #62 were observed with long, dirty nails and facial hair, respectively, despite care plans specifying regular nail care and assistance with facial hair removal. These observations highlight a pattern of neglect in providing essential ADL care to dependent residents.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of four residents, leading to dissatisfaction and potential nutritional issues. Resident #23 expressed dissatisfaction with the facility's food, citing issues such as excessive pepper, tough baked chicken, and overcooked zucchini. The resident also mentioned a lack of responsiveness to concerns since a previous chef left the facility. Resident #26 reported not receiving cereal, which was a regular part of his diet, and being served fish despite having a seafood allergy. The resident also noted a lack of menu options and inconsistent meal preparation. Resident #42 complained about overly spicy food and inadequate breakfast options, including dry toast without butter or jelly, despite being on a renal/carb consistent diet that allowed for sausage. The Registered Dietitian (RD) confirmed the resident's diet should have included sausage but was unsure why it was not provided. Resident #79 expressed dissatisfaction with the food, opting for snacks or meals brought by family instead. The RD acknowledged the resident's carb-consistent diet but had not followed up on her concerns due to being new to the facility. The facility's policy on food and nutrition services aims to provide appropriate, attractive, and palatable food, but the residents' experiences indicate a failure to meet these standards. The Director of Hospitality and the RD were aware of the issues but had not effectively addressed them, partly due to recent staffing changes. The lack of a Certified Dietary Manager and the newness of the RDs may have contributed to the oversight in addressing residents' dietary preferences and needs.
Inadequate Snack Provision for Residents
Penalty
Summary
The facility failed to provide adequate snacks, including bedtime snacks, for a group of residents, leading to complaints about the lack of availability and variety of snacks. Residents, including those with diabetes, expressed dissatisfaction with the limited snack options, such as the absence of healthy snacks like applesauce, peanut butter, fruit, or cheese. They reported having to rely on family and friends to bring in snacks, which caused feelings of frustration, sadness, and hunger. The residents also mentioned that the unit refrigerators were often empty, and there was no personal choice of snacks available. During observations and interviews, it was noted that the facility's snack provisions were inadequate. The Hospitality Director confirmed that residents could only access certain snacks without charge if they were included on their meal trays, otherwise, they would incur a cost. The floor stock list and always available menu were reviewed, revealing limited options such as turkey sandwiches and a lack of fresh fruit or other desired items. Observations of the Americana and Patriot cafes showed minimal snack availability, with one yogurt brought in by a family member and a sign indicating 'STAFF ONLY' access, further highlighting the deficiency in snack provision for residents.
Infection Control Deficiencies in PPE Use and Linen Handling
Penalty
Summary
The facility failed to adhere to Infection Prevention and Control standards, specifically in the use of Personal Protective Equipment (PPE), hand hygiene, and linen transport. On multiple occasions, staff members were observed not following proper protocols. For instance, a Certified Nursing Assistant (CENA) was seen assisting a resident with incontinence care and then offering a drink without removing dirty gloves or performing hand hygiene. Another CENA was observed leaving a resident's room without doffing PPE or performing hand hygiene before entering another room, and then returning to the original room with the same PPE. Additionally, issues were noted with the transport of clean linen. Staff members were seen carrying clean linen against their uniforms without using a barrier, which is against standard practice. Furthermore, another CENA entered a resident's room to assist with bed mobility and perineal skin observation without performing hand hygiene upon entry and improperly handled gloves by pulling them from their pocket without ensuring cleanliness. These actions demonstrate a lack of adherence to infection control protocols, potentially increasing the risk of infection spread among residents.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to maintain the dignity and privacy of its residents, as evidenced by several observations and interviews. Resident #56 was found exposed in their room without adequate privacy measures in place, as a nurse entered the room without ensuring the resident's body was covered. This lack of privacy was a direct violation of the resident's right to a dignified existence. Additionally, the facility did not provide timely and polite assistance to residents, as noted in the case of Resident #6, who expressed dissatisfaction with the delay in being assisted out of bed, and Resident #11, who reported that their call light was not within reach, leading to delays in receiving necessary help. The facility also failed to ensure proper grooming and personal hygiene for its residents. Observations revealed that female residents, such as Resident #135 and Resident #136, were not shaven, despite care plans indicating the need for assistance with facial hair. This neglect in personal grooming contributed to a lack of dignity and respect for the residents. Furthermore, Resident #28 was observed with unkempt hair and facial hair, indicating a failure to provide adequate grooming assistance as outlined in their care plan. The facility's response time to call lights was consistently delayed, as evidenced by the call light timing reports, which showed a significant percentage of call lights taking longer than the acceptable 15-minute response time. This delay in response was corroborated by the Resident Council meeting, where residents expressed frustration over the staff's failure to respond promptly to their needs. The combination of these deficiencies resulted in an environment where residents felt neglected and disrespected, leading to verbalizations of concern and anger, as well as feelings of shame and isolation.
Failure to Incorporate PASARR Recommendations for Specialized Mental Health Services
Penalty
Summary
The facility failed to incorporate recommendations for specialized mental health services from a Preadmission Screening and Annual Resident Review (PASARR) Level II assessment into the care plans of two residents. Resident #26, who was admitted with diagnoses including bipolar disorder and depression, had a PASARR Level II evaluation indicating the need for specialized mental health services. However, the resident's care plan did not include any mention of these specialized services, despite the resident having full cognitive abilities and requiring assistance with all care. Similarly, Resident #59, admitted with diagnoses such as bipolar disorder and a history of suicidal thoughts, also had a PASARR Level II evaluation recommending specialized mental health services. The care plan for this resident lacked any reference to a specialized mental health plan, even though the resident was on antidepressant and antipsychotic medications and had full cognitive abilities. Interviews with the facility's social worker revealed a lack of communication and follow-up with the Community Mental Health agency regarding the specialized mental health plans for both residents. The facility's policy on coordinating assessments with the PASARR program was not adhered to, resulting in the absence of specialized mental health services in the residents' care plans.
Failure to Update Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to update and revise individualized, person-centered care plans to reflect the changing care needs of three residents, leading to potential unmet care needs. Resident #16, who has a history of brain injury, quadriplegia, and multiple pressure ulcers, was observed with severe cognitive decline and dependency on all care. Despite having chronic and new wounds, the care plans for Resident #16 were outdated and did not include specific interventions identified by the wound nurse, such as the use of a low air loss mattress and heel boots. The care plans had not been updated to reflect the current wound status and necessary interventions. Resident #117, diagnosed with Alzheimer's disease and a history of falls, experienced multiple falls within the facility. The resident was found on the floor in other residents' rooms on several occasions, indicating a pattern of wandering. The fall care plan for Resident #117 was outdated and did not include interventions to address the resident's wandering behavior or the use of proper footwear, as recommended by the facility. The Assistant Director of Nursing noted that staff were to monitor the resident and perform frequent room checks, but these interventions were not documented in the care plan. The deficiencies in updating care plans for both residents highlight a lack of timely revision and inclusion of specific interventions to address their current needs. The failure to update care plans with relevant and individualized interventions poses a risk of unmet care needs and potential harm to the residents. The facility's oversight in maintaining accurate and current care plans for residents with complex medical conditions and behavioral issues is a significant concern.
Failure to Monitor and Treat Blood Glucose Levels
Penalty
Summary
The facility failed to adequately monitor and treat blood glucose levels for a resident, leading to a significant change in the resident's condition and subsequent hospitalization. The resident, who had a history of diabetes, end-stage kidney disease, and other medical conditions, experienced multiple episodes of low blood sugar over a period of several days. Despite these episodes, insulin was administered without proper documentation of blood glucose levels or physician notification, contributing to the resident's deteriorating condition. The resident's medical records revealed that insulin was given even after low blood sugar levels were recorded, and there were instances where blood glucose levels were not documented before insulin administration. On several occasions, the resident's blood sugar dropped to dangerously low levels, requiring the administration of glucagon, a medication used to treat severe hypoglycemia. The facility's staff failed to notify the physician of these repeated low blood sugar episodes, preventing timely medical intervention and assessment. The facility's care plan for the resident included specific instructions for managing diabetes, such as holding insulin if blood sugar was below a certain threshold and notifying the primary care provider if blood glucose was critically low. However, these interventions were not consistently followed, as evidenced by the lack of physician notification and continued insulin administration despite low blood sugar readings. The facility's policy on resident change in condition emphasized the importance of contacting the physician when a resident's condition changes, but this protocol was not adhered to in this case.
Failure to Maintain Cleanliness of Resident's Splint
Penalty
Summary
The facility failed to ensure proper management and monitoring of a left arm splint for a resident, resulting in the resident having a soiled hand splint that had not been laundered. The resident, who was admitted with multiple diagnoses including dementia, stroke history, and left-sided weakness, was observed with a very soiled splint that he wore at night. The resident confirmed that he did not have a second splint and was unsure if the existing one had ever been washed. The Restorative Nurse indicated that the resident was initially wearing the splint all the time, but it was later changed to nighttime use only. The nurse acknowledged that there should be an order for the splint and that nurses were responsible for assisting the resident with it. However, there was no clear responsibility for ensuring the splint was cleaned, and a policy for hand splints was not provided. The resident's care plan included the use of assistive devices and skin checks, but did not specify when the splint should be worn or cleaned.
Resident Safety Compromised During Transfer
Penalty
Summary
The facility failed to ensure the safety of a resident with severely impaired cognition and a history of combativeness, resulting in an accident that caused a laceration to the resident's left eyebrow. The resident, who had diagnoses including Dementia, Parkinson's Disease, and Alzheimer's, required assistance with all Activities of Daily Living (ADLs) and had documented behaviors of swinging and kicking at staff. On the day of the incident, the resident was involved in two separate events where they exhibited aggressive behaviors. At 11:30 AM, the resident was found on the floor and was combative when staff attempted to assist them. Later, at 1:00 PM, while being transferred from the bathroom to bed using a Sara lift, the resident hit their left eyebrow against the lift due to continued aggressive behavior. The Assistant Director of Nursing (ADON) confirmed that the resident was a one-person assist for transfers and ADL care, and the care plan did not mention the use of a Sara lift. However, the resident was assisted with the lift by just one Certified Nursing Assistant (CENA) despite having exhibited aggressive behaviors earlier that day. The ADON acknowledged the resident's behaviors and the recent changes in psychotropic medication but did not provide clarity on why the mechanical lift was used with only one staff member present, especially given the resident's recent behavioral history.
Failure to Document and Address Resident's Nutritional Needs
Penalty
Summary
The facility failed to adequately document food acceptance, provide suitable utensils, and assess, monitor, and notify the physician of a significant weight loss for a resident. Observations revealed that the resident's meals were often left untouched, and there was a lack of staff assistance during meal times. The resident struggled with using the provided utensils, which were sometimes plastic, and had difficulty consuming meals independently. Despite the resident's impaired cognition and need for setup or clean-up assistance, there was no documented effort to assist the resident during meals, leading to numerous undocumented meal consumptions. The resident experienced a significant weight loss of 5.08% over a month, with a steady decline in weight from 205.6 pounds to 187 pounds over several weeks. The nutrition progress notes indicated that the resident's appetite had declined since admission, and there was inconsistent documentation of meal and snack consumption. The dietary staff increased nutritional supplements but failed to document the provision of snacks adequately. Additionally, there was no documented notification to the physician regarding the resident's significant weight loss, and the physician was unaware of the issue during a visit.
Improper Management of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper cleaning, sanitization, and storage of respiratory equipment for residents, leading to potential cross-contamination and respiratory issues. Resident #624's CPAP machine was found dirty and not stored in its designated bag, despite physician orders requiring daily cleaning. Additionally, there was no care plan addressing the resident's CPAP or apnea needs. Resident #60's oxygen concentrator was alarming, and the oxygen tubing was on the floor, not supplying oxygen to the resident, indicating a lack of proper equipment management. Resident #2 was observed with oxygen tubing in place, but the oxygen concentrator was not turned on, leaving the resident without supplemental oxygen for an extended period. The tubing was also not dated, contrary to facility policy requiring weekly changes and labeling. The Director of Nursing confirmed the requirement for labeling and dating the tubing, highlighting a lapse in adherence to the facility's oxygen delivery system policy.
Failure to Monitor Dialysis Port Leads to Antibiotic Use
Penalty
Summary
The facility failed to assess and monitor the dialysis port for a resident, resulting in the resident starting on antibiotics. The resident, who is of advanced age, was admitted with diagnoses including end-stage renal disease, hypertensive chronic kidney disease, heart failure, and dependence on renal dialysis. Observations revealed a dressing on the resident's upper right chest where the dialysis port is located, but there was no physician order to assess and monitor the dialysis port for any changes. The resident was receiving antibiotics at the dialysis center, but was unsure of the reason. Further record review showed that the resident had been started on Vancomycin on a previous date due to drainage noted at the dialysis port site. An order to monitor the port site for signs or symptoms of infection every shift was only dated after the issue was identified. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the facility did not have a policy for assessing and monitoring dialysis port sites or shunts, and that dressings were changed every seven days or as needed, unless altered at dialysis.
Medication Cart Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and organization of medication carts, as observed during a survey. Three out of eight medication carts were found to contain crushed pills, pieces of loose paper, silver shards of foil from medication cartridges, and dust at the bottom of the drawers. This was observed during multiple inspections of the medication carts on different days, with the presence of these contaminants indicating a lack of proper cleaning and maintenance. The deficiency was noted in the medication carts located in the Patriot and Wheels units, specifically affecting the second, third, and fourth drawers of the carts. Interviews with nursing staff revealed a lack of clarity regarding the responsibility for cleaning the medication carts. Nurses RN I, LPN J, and RN K each stated that they had cleaned the carts during their previous shifts but were unsure who was responsible for regular cleaning. The Director of Nursing indicated that second shift nurses were supposed to clean the medication carts, suggesting a possible communication breakdown or lack of adherence to cleaning protocols. This lack of clear responsibility and oversight contributed to the unsanitary conditions observed in the medication carts, posing a risk of cross-contamination and potential medication errors.
Failure to Document Antibiotic Use and Indications
Penalty
Summary
The facility failed to ensure that antibiotic orders for two residents included the reason for use and that antibiotic use was tracked, leading to potential inappropriate antibiotic use. Resident #23, who had a history of stroke, epilepsy, and hypertension, was prescribed Doxycycline without a documented diagnosis or indication for its use. The physician's notes and the Infection Control Log did not provide any information on why the antibiotic was prescribed, and the resident was not listed as having an infection or receiving antibiotics in the relevant months. Similarly, Resident #79, with diagnoses including diabetes, morbid obesity, and a stage 4 sacral pressure ulcer, was prescribed Bactrim for prophylaxis without a clear reason documented in the physician's orders. Although there was a note about recurrent UTIs, this was not reflected in the orders, and the progress notes did not mention the antibiotic. The Infection Prevention and Control Nurse acknowledged the lack of documentation for the antibiotic use during an interview, stating that the electronic medical record system did not allow for adding diagnoses with the orders. The facility's Antibiotic Stewardship policy, which aims to promote appropriate antibiotic use and reduce adverse events, was not effectively implemented, as evidenced by the lack of documented indications for antibiotic orders. The report highlights the facility's failure to adhere to its own policy and the CDC's guidelines on antibiotic use, which could contribute to antibiotic resistance and other adverse effects.
Failure to Complete Comprehensive Fall Investigation and Notify Physician
Penalty
Summary
The facility failed to complete a comprehensive fall investigation and notify a physician of X-ray results for a resident, resulting in significant delays in medical treatment. The resident fell in the bathroom, hitting his face on the floor, and sustained a nasal bone fracture and a fracture on the left side of the maxilla. Despite these injuries, the facility did not send the resident to the hospital immediately, nor did they order imaging until the following day. The X-ray results, which recommended a CT scan, were not communicated to the physician for seven days, during which the resident developed subacute bilateral subdural hematomas. The facility's documentation surrounding the incident was incomplete and inconsistent. The fall event report lacked critical details, including the identity and statements of the CNA and nurses involved, the resident's statement, and the specifics of the X-ray order and results. Additionally, several sections of the fall event report were left incomplete, such as pain observation, neurological checks, and possible contributing factors. This lack of thorough documentation contributed to the delay in appropriate medical intervention. Interviews with facility staff and family members revealed discrepancies in the accounts of the fall and subsequent actions taken. The CNA involved in the incident initially left the resident alone in the bathroom, contrary to the care plan that required one assistance for toileting. The facility's failure to notify the physician promptly and the lack of clear and consistent documentation led to a significant delay in the resident receiving necessary medical evaluation and treatment for his injuries.
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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