Heritage Manor Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Detroit, Michigan.
- Location
- 9500 Grand River Ave, Detroit, Michigan 48204
- CMS Provider Number
- 235234
- Inspections on file
- 35
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Heritage Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Kitchen sanitation and storage deficiencies were identified when a Dietary Aid was observed without a beard guard while operating the dish machine, and multiple kitchen surfaces were found soiled or not properly cleaned, including a ceiling tile area, the ice machine panel, the ice scoop holder, and walk-in cooler surfaces and racks. Surveyors also observed wet pans and dishes stacked before air-drying, ladles stored bowl side up, and damaged foam insulation on the freezer exterior with broken pieces on the floor.
Dirty laundry barrels were observed in the laundry room being used to transport washed linen to the dryer and then to the clean linen area. The barrels contained paper tissue debris, dried corn kernels, and other unidentifiable debris, and the HM confirmed they were dirty and needed to be kept clean. The facility’s Laundry policy stated that linen can become contaminated from environmental contaminants or contaminated hands and that carts used for clean linen must be cleaned when visibly soiled and on a routine schedule.
Kitchen refrigeration equipment was not properly maintained when the reach-in juice cooler had damaged, loose door gaskets, the walk-in cooler had an unsecured metal threshold strip, and the walk-in freezer had heavy ice and condensation on the door. The DM stated the freezer door did not fully close, and the maintenance log showed repeated freezer door problems with incomplete documentation.
Kitchen and janitor's closet maintenance deficiencies were identified when surveyors observed a missing metal baseboard outside the walk-in cooler, standing water on the chemical closet floor, and peeling paint with moisture exposure on the cinder block walls. The maintenance log showed the closet leak had been ongoing for months with no documented solution, and interviews with the DM, NHA, and Corporate Maintenance Director confirmed the leak had been repeatedly addressed but not properly resolved.
A resident trust fund was not maintained in a separate interest-bearing account and interest was not consistently credited to resident accounts. Records for multiple residents showed conflicting spreadsheets, no actual bank statements were produced to verify the account setup, and the corporate accountant and business owner acknowledged the funds were co-mingled with the facility’s general account and that interest had not been properly pro-rated.
Resident trust funds were not maintained with a separate accounting system or handled according to GAAP for 35 residents. The BOM and corporate accountant provided inconsistent Excel records instead of matching bank statements, and the actual statements later showed commingling with the facility account, unclear interest handling, and withdrawals that did not match resident activity.
Advance directives were not consistently reviewed or updated for several residents. One resident had conflicting code status documents showing both Full Code and DNR, and the chart lacked documentation that the legal guardian was consulted about the change. For other residents, records showed advance directive forms or code status entries, but there was no documentation of periodic review, updating, or discussions with residents or legal representatives, despite staff stating these reviews should occur routinely and be documented.
A resident with intact cognition and multiple medical conditions reported a returned check despite believing they had sufficient funds. When the BOM assisted with reviewing finances, the resident’s wallet was found in a social service employee’s desk and the bank card was missing. Speakerphone calls with the bank, overheard by the BOM and an LPN, revealed a large credit card payment from the resident’s account that caused an overdraft and numerous disputed transactions at various retailers, gas stations, and an airline. Bank staff indicated they had been tracking the involved employee for a cash advance with invalid data, and the resident’s report of missing property and unauthorized charges met the facility’s own definition and indicators of misappropriation of resident property.
A resident with multiple chronic conditions and intact cognition had a check to the facility returned for insufficient funds, prompting the BOM to review the resident’s finances. The resident believed there was sufficient money in the account, did not have their bank card or wallet, and stated that the social worker had it. The BOM found the resident’s wallet in the social service office without the bank card, and during a call with the bank learned of large credit card payments and transactions the resident did not recognize, then identified a social service employee as a possible user of the card. Although the facility’s policy required prompt reporting of all alleged violations to the Administrator and State Agency, the BOM, who knew the NHA was the abuse coordinator, reported the concern only to the company’s owner and did not notify the abuse coordinator or State Agency within the required timeframe.
A resident with intact cognition and multiple medical diagnoses discovered that a check to the facility had bounced despite believing there were sufficient funds, and reported that their bank card and wallet were held by a social service employee. The Business Office Manager retrieved the wallet from a social services desk, noted the bank card was missing, and participated in speakerphone calls with the bank, during which large, disputed transactions and an overdraft-causing payment were disclosed, and the bank linked suspicious activity to the staff member holding the card. An MDS Coordinator/LPN overheard these calls, recognized that someone was stealing from the resident, but was never interviewed, and no statement was obtained. The facility’s investigation file lacked this witness interview and did not include an interview with the implicated staff member, resulting in an incomplete investigation that did not meet the facility’s abuse, neglect, and exploitation policy requirements.
Failure to develop and implement a care plan for a resident with a supra-pubic catheter. The resident had an order for catheter care, but the MDS triggered an indwelling catheter care area assessment and there was no urinary or catheter care plan, only a UTI care plan without catheter interventions. During observation, the catheter tubing was pulling tightly, the collection bag was on the floor with about 1 liter of urine, the anchor was not secured, and the insertion site was open to air with a small moist ulcer and redness around the stoma. An LPN noted the site should be covered and the bag emptied and lifted off the floor, and the DON stated a care plan had been started.
A wheelchair-dependent resident who was safe to smoke repeatedly missed smoke breaks because access to the outside smoking area depended on a working elevator and delays caused the resident to arrive after the designated smoking time had ended. The resident, who had diagnoses including seizures, hemiplegia/hemiparesis, heart disease, cerebral infarction, anxiety, and depression, stated this happened often and was very upsetting. The resident’s care plan and smoking risk assessment indicated the resident had the ability to smoke, and facility staff stated the smoke break ended when the scheduled time was over.
A resident with a supra-pubic catheter was observed with tubing pulling tightly, the drainage bag on the floor, and the anchoring device not secured to the body. The insertion site was open to air with no dressing, and a shallow ulcer with redness was present around the stoma while the resident said the catheter was bothering them. The EHR showed a physician order to ensure the anchor was in place, but there was no catheter care plan and no catheter care interventions in the UTI care plan.
Pureed vegetables were not prepared to the proper consistency for four residents on pureed diets. During lunch service, pureed green beans were observed sitting in water on the hot stove because there was not enough steam table space, and the beans were found to be lumpy when tasted by the DM and State Surveyors. The RD stated pureed food should be smooth like pudding.
A resident with schizoaffective disorder, dementia, and no prior eye disease was in a wheelchair in a hallway when a housekeeping manager repeatedly sprayed a Clorox bleach cleaner directly into the resident’s face while a housekeeper held the wheelchair in place. A CNA witness reported the manager made a threatening statement and then sprayed more bleach, recognizing the product by its bleach odor. The resident later reported that staff sprayed a chemical in his eyes and that his right eye remained painful. Medical records documented evaluation for eye pain and chemical exposure, with findings of epithelial irritation, corneal haze, conjunctival redness, periorbital puffiness, and chemical damage to the front of the eyes, attributed to the chemical exposure during the confrontation with staff.
A CNA exploited a resident with moderate cognitive impairment by using the resident's debit card to make unauthorized purchases totaling $1,900. The incident was discovered after a declined payment attempt, and the CNA admitted to the misuse before resigning. The resident, who had multiple medical conditions, suffered a significant financial loss as a result.
Surveyors identified multiple sanitation and maintenance deficiencies in the food service area, including excessive sanitizer concentration, soiled and corroded equipment such as the ice machine and can opener, and a broken microwave handle. These issues affected 107 residents who consume food products, and record review indicated a gap between facility policy and actual practice.
The facility did not effectively clean and maintain key areas, as evidenced by heavily soiled PTAC unit filters and dining room floors, as well as recurring flooding in the kitchen floor drain. Housekeeping staffing levels and maintenance practices were insufficient to prevent the accumulation of dirt, dust, and food residue, and to address ongoing wastewater issues, resulting in an environment that was not consistently safe, sanitary, or comfortable for residents, staff, and the public.
A resident with paraplegia and a recent surgical repair was transferred to another LTC facility without complete transfer or discharge documentation. The electronic health record lacked a transfer form, discharge plan, and summary note, and interviews with the DON and NHA confirmed that required information was not provided to the receiving provider, contrary to facility policy.
The facility failed to maintain accurate records for controlled drugs in its back-up box, leading to discrepancies in narcotic counts. The DON could not explain the reconciliation process, and the pharmacist confirmed discrepancies between the expected and actual narcotic counts. This failure to adhere to the facility's Pharmacy Services policy resulted in potential drug diversion and unavailability of medications for residents.
The facility failed to address MRR recommendations timely for two residents, leading to the continuation of unnecessary medications. A pharmacist's recommendations to adjust insulin and Xanax regimens were not reviewed or acted upon by the physician within the expected timeframe, as acknowledged by the DON.
A resident with a history of stroke and a ruptured right eye received only two doses of prescribed erythromycin ophthalmic solution instead of the full 14-day course due to a transcription error in the MAR. This error resulted in the potential for prolonged symptoms of a right eye infection. The DON confirmed the transcription mistake, acknowledging the resident should have received the medication for 14 days.
A facility failed to maintain an accurate Antibiotic Stewardship Program, leading to a resident's antibiotic prescription for an eye infection not being documented or monitored. The resident was prescribed Erythromycin ophthalmic solution for 14 days but only received two doses. The Infection Control Nurse was unaware of the prescription, and the oversight was attributed to the resident not being listed on the infection report log.
The facility failed to properly screen, educate, offer, and document influenza vaccinations for several residents, resulting in incomplete and invalid consent forms. One resident consented to the vaccine but did not receive it, and others were not properly offered the vaccine, despite the facility's policy requiring annual vaccination offers and education.
The facility failed to maintain cleanliness and repair on multiple floors, affecting residents' living conditions. Observations included cracked floor tiles, broken equipment, and persistent odors on the third floor, while the fifth and second floors had issues like non-working elevator lights, urine odors, and damaged wheelchairs. Interviews revealed a lack of effective monitoring and an incomplete maintenance checklist.
A facility failed to follow medication administration standards, including not priming an insulin pen, improperly administering medications through a PEG tube, and a transcription error in a resident's medication record. An LPN did not prime an insulin pen before use, administered multiple medications through a PEG tube without individual flushing, and a transcription error led to a delay in correcting a resident's medication dosage.
The facility failed to provide adequate grooming and hygiene care for three residents, resulting in unmet hygiene needs and emotional distress. One resident had unkempt, matted hair with lint, another had tangled hair in a knotted ponytail, and a third had a visible beard and soiled clothing. Staff interviews revealed confusion about grooming responsibilities, with no requests made for grooming services on the third floor.
A resident with a supra-pubic catheter experienced discomfort and potential risks due to inadequate catheter care. Observations showed the catheter tubing was taut and not properly secured, with the collection bag often at the bladder level. The resident reported discomfort and a history of catheter dislodgment. Staff interviews revealed inconsistent care practices, and the resident's care plan instructions were not consistently followed.
A facility failed to justify the use of a PRN antianxiety medication, Xanax, for a resident with a history of stroke and depression. The resident's prescription lacked a 14-day stop date and documentation for continued use. Staff interviews revealed that the oversight was missed by the visiting psychiatry group responsible for monitoring psychotropic medications.
A facility failed to ensure proper communication and documentation of hospice services for a resident with severe cognitive impairment, resulting in a lack of coordinated care. The hospice logbook lacked nursing notes, hindering effective communication with hospice staff. The Corporate Consultant confirmed missing notes, which should have been in the resident's EMR. The DON acknowledged the issue but could not explain how coordination was possible without the nurse's documentation.
The facility failed to implement enhanced barrier precautions for two residents, leading to potential transmission of infectious organisms. Staff provided care without PPE, despite residents having conditions like stage IV pressure ulcers and bacterial conjunctivitis. Interviews revealed a lack of adherence to PPE protocols, despite staff training.
The call light system on the third floor of the facility was not functioning, leading residents to use bells for assistance. An irate resident had damaged the main box, causing the malfunction. Residents reported difficulties in getting help as nurses might not hear the bells. The facility had an undated estimate for repairs but no signed contract or timeline for completion.
The facility failed to update care plans for two residents after multiple falls, despite their impaired cognition and need for assistance with mobility. One resident's care plan had not been updated since 2023, and another had outdated and incomplete interventions. The DON acknowledged the need for updates per the facility's policy.
A resident with impaired cognition and mobility issues did not receive a concave mattress as specified in their fall care plan. The DON confirmed the use of a regular mattress instead, contrary to the care plan's intervention for fall prevention.
The facility failed to monitor the weights and nutritional status of two residents who refused to be weighed, resulting in significant weight changes going undetected. One resident experienced a 16.3% weight loss over two months, while another had a 14.6% weight gain. Nutritional assessments and care plans were not updated or revised as required, and the facility did not notify physicians or use alternative assessment tools.
A hospice resident with a history of stroke was found unresponsive on the floor with a pool of blood around the head due to the facility's failure to implement fall prevention measures and provide adequate staffing. Despite being assessed as 'not at risk' for falls, the resident's care plan lacked fall prevention interventions, and a floor mat was not in place. Staffing shortages further contributed to inadequate supervision, as the night shift LPN had to manage two floors with only one aide, impacting the ability to monitor the resident effectively.
The facility failed to maintain a functional call system, affecting residents in specific rooms and shower areas. Observations revealed missing call light panels and non-functional alerts, with some residents unable to use their call lights for weeks or months. Despite requests, the facility did not provide audit logs, and maintenance issues were not promptly addressed.
The facility failed to maintain a safe, clean, and comfortable environment, with issues such as missing elevator handrails, gnats in rooms, and unresolved maintenance concerns like non-functional showers and broken blinds. Maintenance logs showed numerous unresolved entries, and staff interviews revealed a breakdown in the process for addressing these issues.
The facility failed to consistently assist the Resident Council in organizing monthly meetings and addressing concerns. Complaints included long call light wait times and insufficient seating during meetings. The facility lacked meeting minutes and follow-up documentation from November 2023 to April 2024, despite having a policy supporting resident group organization.
The facility failed to promptly and thoroughly investigate allegations of abuse and neglect, including an injury of unknown origin for a hospice patient found unresponsive with a serious head injury. The investigation was delayed, incomplete, and submitted late to the State Agency. Additionally, other incidents involving allegations of abuse between residents were not promptly investigated, violating the facility's policy and regulatory requirements.
Two residents expressed grievances that were not followed up by the facility, leading to frustration and communication issues. One resident reported missing personal belongings, while another had concerns about call light wait times and medication administration. The facility's grievance policy requires prompt resolution, but no grievance forms or follow-up evidence were provided.
A hospice patient was found unresponsive with a head injury of unknown origin, but the incident was reported to the State Agency two days late. The facility's policy requires immediate reporting of such incidents, but the Nursing Home Administrator was not informed in a timely manner, leading to a delay in reporting.
Kitchen sanitation and storage deficiencies
Penalty
Summary
The facility failed to ensure kitchen staff used proper hair restraints when a Dietary Aid operating the dish machine was observed with facial hair not covered by a beard guard. During the kitchen tour, multiple sanitation concerns were identified, including a ball of dust protruding from a ceiling tile above the prep handwashing sink, a stained panel inside the ice machine that left brown smears when wiped, and an ice scoop holder containing standing discolored water with loose brown sediment. The Dietary Manager acknowledged the beard guard issue and agreed the ice machine panel was not properly cleaned. Additional observations showed a metal threshold strip inside the walk-in cooler was not securely fixed to the floor and part of it was missing, with a predominately brown substance around the displaced area that smeared when wiped. Wire racks inside the walk-in cooler were discolored and also left brown smears on a paper towel during a wipe test. Clean pans, sheet pans, and a plate in the dispenser were observed with droplets of water, and three ladles were hanging bowl side up. A green insulation foam board on the outside of the walk-in freezer was chipped and crumbling, with broken white foam pieces on the floor. The Dietary Manager stated surfaces within the kitchen should be smooth and cleanable, and the Corporate Maintenance Director said the foam insulation was no longer necessary and could be removed.
Dirty Linen Transport Barrels Observed in Laundry Room
Penalty
Summary
The facility failed to ensure proper handling of clean linen when two blue laundry barrels used to transport washed linen to the dryer and from the dryer to the clean linen area were observed in the laundry room with paper tissue debris, dried corn kernels, and other unidentifiable debris. During the tour, the Housekeeping Manager confirmed the barrels were dirty and stated they needed to be kept clean. An undated Laundry policy provided by the facility stated that linen can become contaminated with pathogens from contact with intact skin or body substances, or from environmental contaminants or contaminated hands, and that separate carts are to be used for transporting clean and contaminated linen and cleaned when visibly soiled and routinely according to the facility schedule.
Kitchen Refrigeration Equipment Not Properly Maintained
Penalty
Summary
Keep all essential equipment working safely was not met when the facility failed to ensure the reach-in juice cooler, the inside of the walk-in cooler, and the walk-in freezer were properly maintained and in good working order. During a kitchen tour with the Dietary Manager, the door gaskets of the reach-in juice cooler were observed damaged and loose in several places. A metal threshold strip inside the walk-in cooler was not securely fixed to the floor, and there was a significant build-up of ice and condensation on the outside of the walk-in freezer door. The Dietary Manager stated the freezer door did not fully close. The Maintenance/Dietary Service Log showed ongoing issues with the freezer door, including an entry on 10/30/25 noting the freezer door was cracked and another on 2/1/26 noting the freezer had built up on the door with no solution documented. During interview, the Nursing Home Administrator stated the facility was actively correcting the kitchen-related concerns presented. The report also noted the maintenance supervisor was supposed to check the dietary maintenance log at least once a week.
Kitchen and Janitor's Closet Maintenance Deficiencies
Penalty
Summary
The facility failed to keep the area outside the walk-in cooler and the janitor's closet in good repair and cleanable condition. During a kitchen tour with the Dietary Manager, a metal baseboard measuring approximately eight by four inches was missing outside the walk-in cooler. In the janitor's closet, the concrete floor was damp with standing water, and portions of the cinder block walls showed peeling paint and moisture exposure. Record review and interviews showed the leak in the chemical closet had been ongoing for months. The Maintenance/Dietary Service Log documented that on 12/1/25 the chemical closet still had leaks from the 2nd floor, and on 1/7/26 it was still leaking, with no solution documented for either entry. The Dietary Manager stated the maintenance supervisor was supposed to check the dietary maintenance log at least once a week. The Nursing Home Administrator said maintenance had fixed the ceiling leak more than once but probably not correctly, and the Corporate Maintenance Director said the leak was coming from a supply line located inside the concrete and that quotes were being obtained to replace it.
Resident Trust Funds Not Properly Held or Credited With Interest
Penalty
Summary
The facility failed to deposit resident personal funds in an interest-bearing account separate from the facility’s operating account and failed to credit all interest earned to the resident trust fund account. The deficiency affected R90 and 27 of 36 residents who had over $100 in the resident trust fund account in January 2026. R90 was admitted with multiple diagnoses including congestive heart failure, had a court-appointed legal guardian, and was documented on the annual MDS as cognitively intact and totally dependent on staff for all ADLs. R90 reported receiving $60.00 per month, but stated it was always late, and the legal guardian confirmed the monthly payment was received on the 5th of each month rather than the 1st. During review of the resident personal funds records, the Business Office Manager produced facility-created Excel spreadsheets for 12/2025, 1/2026, and 2/2026, but there was no credit or documentation showing interest accrued to the resident trust fund. The BOM could not produce actual bank statements and stated the corporate accountant managed the trust funds. The corporate accountant initially stated the trust fund was in an interest-bearing account but was kept with the facility’s account and that $1.00 per month was deposited into each resident’s account; however, the reviewed spreadsheets did not show those deposits. Later, the accountant provided updated spreadsheets showing $1.00 deposits and then pro-rated interest amounts, but could not explain the discrepancies. The NHA stated they did not handle the trust fund, and the facility business owner later stated the resident trust fund was co-mingled with the facility’s general bank account and interest had not been pro-rated accordingly. The facility policy required resident funds over the applicable threshold to be deposited in an interest-bearing account separate from operating accounts with all interest credited to resident accounts.
Resident Trust Funds Not Separately Accounted For
Penalty
Summary
The facility failed to maintain a separate accounting system for resident trust funds and did not use generally accepted accounting principles for the personal money of 35 residents using the resident trust fund account. During review of the personal fund records, the Business Office Manager produced facility-created Excel spreadsheets showing resident activity, but could not produce actual bank statements and stated the corporate accountant managed the trust funds. The corporate accountant reported the trust fund was in an interest-bearing account and said the facility deposited $1.00 per month into each resident’s account, but was unable to provide consistent banking statements to confirm interest deposits for the months reviewed. Further review showed multiple inconsistent versions of the resident trust fund spreadsheets. One version indicated each resident received $1.00 deposits for the months reviewed, while another showed each of the 35 residents received a prorated amount of interest each month. Actual bank statements were eventually provided, but they did not match the spreadsheet amounts, did not show how interest was determined, and reflected significant weekly deposits and withdrawals that did not match the residents’ personal facility statements. The Business Owner stated the resident trust fund was commingled with the facility’s bank account and that money was being withdrawn at the end of each month so it would not get levied by an outside entity.
Advance Directives Not Periodically Reviewed or Properly Updated
Penalty
Summary
The facility failed to provide periodic reviews and to adequately update Advance Medical Directives for five residents reviewed for advance directives. The record review and interviews showed that the facility did not consistently document discussions with residents or legal representatives about whether advance directives should be formulated, continued, or changed, and there was no evidence that advance directives were periodically reviewed as part of the comprehensive care planning process. For one resident, the electronic record showed conflicting code status documents: a face sheet and a later Resident Code Status form listed the resident as Full Code, while an earlier Code Status/Do Not Resuscitate Directive form identified the resident as DNR and was signed by the resident’s legal guardian, the physician, and two witnesses. The resident’s legal guardian was verified in the record, but the chart did not contain documentation showing the guardian had been consulted about the code status change. During interview, the social worker could not explain the conflicting forms and stated the signatures were not hers, and the legal guardian stated the resident was DNR and that no one had asked about changing it. For four other residents, the records showed code status or advance directive documents, but no documentation supported periodic review or updating of those directives. One resident was cognitively intact with diagnoses including anemia, hypertension, peripheral vascular disease, renal failure, diabetes, and hyperlipidemia; another had severe cognitive impairment and a legal guardian; a third had moderate cognitive impairment and a legal guardian; and a fourth was cognitively intact and also had a legal guardian. The social worker stated advance directives are reviewed at admission and should be reviewed at least quarterly, and the nursing home administrator stated they should be reviewed quarterly and updated yearly, with the resident and guardian signing and the discussion documented.
Failure to Safeguard Resident Funds from Misappropriation by Staff
Penalty
Summary
The facility failed to protect a resident’s money from misappropriation when a social service employee maintained possession of the resident’s wallet and bank card and the resident’s funds were used for unauthorized transactions. The resident, who had diagnoses including epilepsy, congestive heart failure, depressive disorder, and anxiety disorder, but was documented as cognitively intact on the MDS, reported having over $4000 in their checking account after being notified that a check written to the facility had been returned for insufficient funds. When the Business Office Manager (BOM) assisted the resident in reviewing their finances, it was discovered that the resident did not have their bank card or wallet in their possession and stated that the social service employee had it. The BOM located the wallet in the social service employee’s desk, and when the wallet was returned to the resident, the bank card was missing. With the BOM present, the resident contacted their financial institutions via speakerphone and granted permission for the BOM to participate in the calls. Bank staff reported that the resident’s credit card payment in the amount of $6303.17 had been made from the resident’s account, causing an overdraft and resulting in the returned check. The bank also listed multiple transactions on the resident’s bank card with various retailers, gas stations, and an airline that the resident disputed. During these calls, the financial institution indicated they had been tracking the social service employee for a cash advance with invalid data. Another staff member, the MDS Coordinator/LPN, overheard the speakerphone conversations and understood that someone was stealing from the resident. The facility’s own abuse, neglect, and exploitation policy defined misappropriation of resident property as the wrongful use of a resident’s belongings or money without consent and identified resident reports of theft or missing property as possible indicators of abuse, which were present in this situation.
Failure to Timely Report Suspected Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely reporting of an allegation of misappropriation of resident property to the State Agency and to the facility’s abuse coordinator. A resident with diagnoses including epilepsy, congestive heart failure, depressive disorder, and anxiety disorder, and documented as cognitively intact, had written a check to the facility that was returned for insufficient funds. The Business Office Manager (BOM) received notice of the returned check and, upon speaking with the resident, learned the resident believed there was over $4,000 in the account and did not have their bank card or wallet, stating that the social worker had it. The BOM then located the resident’s wallet in the social service office, but the bank card was missing. During a speakerphone call with the bank, the BOM and resident were informed that the resident’s credit card payment had overdrawn the account and that there were several transactions the resident did not recognize. The bank asked if they knew who might be using the card, and the BOM identified a social service employee, with the bank indicating that this person had been tracked for a cash advance with invalid data. Despite suspecting fraudulent activity toward the resident on the date the returned check was identified, the BOM did not report the suspected misappropriation of resident property to the facility’s abuse coordinator, who was the Nursing Home Administrator (NHA), and did not report the allegation to the State Agency. Instead, the BOM contacted the company’s owner by text and later by phone to discuss the suspected misappropriation. The NHA, who later reported the allegation to the State Agency, stated that the BOM was aware of the possibility of misappropriation when the check was returned and acknowledged that the BOM should not have bypassed the abuse coordinator. The facility’s written abuse, neglect, and exploitation policy required reporting all alleged violations to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes, including not later than 24 hours for events that do not involve abuse and do not result in serious bodily injury. The BOM acknowledged awareness of the abuse policy and that they did not follow protocol when they failed to report the suspected misappropriation as required.
Failure to Thoroughly Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of misappropriation of resident property involving one resident. The Nursing Home Administrator (NHA) was informed by the corporate office that a social service employee (SSE M) was suspected of stealing money from a resident after a check written to the facility was returned for insufficient funds. The Business Office Manager (BOM G) spoke with the resident, who reported having over $4000 in the bank but did not have their bank card or wallet, stating that the social worker had it. BOM G went to the social services office and learned from Social Worker K that SSE M had the resident’s wallet in their desk. When the wallet was returned and reviewed with the resident, the bank card was missing. During a speakerphone call with the financial institution, in the presence of BOM G, the bank reported that the resident’s credit card balance had been paid off with a large payment that overdrew the account and listed transactions the resident disputed; the bank also indicated they had been tracking SSE M for a cash advance with invalid data. The resident, who had intact cognition per a recent MDS and diagnoses including epilepsy, congestive heart failure, depressive disorder, and anxiety disorder, expressed awareness that someone had allegedly stolen their money and suspected the social worker. The investigation conducted by the facility was incomplete and did not follow its own written abuse, neglect, and exploitation policy requiring identification and interviews of all involved persons and witnesses. Although the MDS Coordinator/LPN N was present in the office during the speakerphone calls with the financial institutions, overheard the details of the disputed transactions, and recognized that someone was stealing from the resident, LPN N was never interviewed and did not provide a statement because they were not asked. The facility’s Facility Reported Incident (FRI) file lacked any interview or statement from this witness. SSE M, who had been in possession of the resident’s bank card, was not interviewed because they resigned, and the FRI ultimately documented the allegation of abuse as inconclusive. This failure to interview all individuals with knowledge of the events and to fully document their accounts constituted a failure to conduct a complete and thorough investigation of the alleged misappropriation of resident property.
Failure to Develop and Implement Supra-Pubic Catheter Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with a supra-pubic indwelling urinary catheter. The resident was admitted with multiple diagnoses, including neuromuscular dysfunction of the bladder, and had a physician order dated 2/2/26 for urinary catheter care that included ensuring the anchor was in place. The annual MDS indicated the resident had a supra-pubic catheter, and Section V triggered urinary incontinence/indwelling catheter as a care area assessment, but there was no urinary or catheter care plan. The resident did have a care plan for urinary tract infection initiated on 2/16/26, but it did not include catheter care interventions. During observation on 3/4/26, the resident was seated on the bed with catheter tubing pulling tightly downward from under the shirt. The collection bag was resting on the floor and contained approximately 1 liter of urine. The resident stated, "It's bothering me." The anchoring device was present but not adhered to the resident's body, the insertion site was open to air with no dressing, and a small shallow pink, moist ulcer with surrounding redness was observed around the stoma. The waistband of the resident's sweatpants appeared to rest directly over the catheter insertion site. An LPN stated the site should be covered, the bag should be emptied and picked up off the floor, and confirmed the anchoring device was not attached correctly. On 3/6/26, the DON stated there were orders to cleanse and dress the site every day and as needed, that a care plan had been started, and that there was no policy for resident care planning.
Missed Smoking Breaks for Wheelchair-Dependent Resident
Penalty
Summary
The facility failed to assist a wheelchair-dependent resident, who relied on the elevator to get outside to smoke, resulting in missed smoking opportunities. The resident was observed waiting in a wheelchair at the 2nd floor elevator at approximately 1:00 PM and later at the 1st floor elevator at approximately 1:20 PM. When asked whether they had gone outside to smoke, the resident stated they had missed it. The resident reported that smoke breaks were often missed because only one of the building’s two elevators was working and it could take up to 30 minutes to get on the elevator due to residents and staff waiting to use it. The resident also stated it was very upsetting to miss smoke breaks and that if the break was missed, the door was closed and smoking was not allowed. Record review showed the resident was admitted with diagnoses including seizures, hemiplegia and hemiparesis, heart disease, cerebral infarction, anxiety, and depression. The resident’s MDS indicated no cognitive impairment and that partial moderate assistance was needed for transfers from bed to wheelchair. A smoking risk assessment identified the resident as safe to smoke, and the care plan indicated the resident had the ability to smoke. Facility smoking times were posted as 9:15 AM, 1:00 PM, and 5:15 PM. The Activity Director stated that once the smoke break was over, activity staff moved on to other responsibilities and the smoke break ended. The Nursing Home Administrator stated the resident should be allowed to smoke. The facility policy stated that any resident deemed safe to smoke would be allowed to smoke in designated smoking areas at designated times and in accordance with the care plan.
Improper Supra-Pubic Catheter Care and Site Management
Penalty
Summary
The facility failed to implement appropriate indwelling urinary catheter care for one resident with a supra-pubic catheter. On 3/4/26, the resident was observed seated on the bed with catheter tubing pulling tightly downward from under the T-shirt, the collection bag resting on the floor with approximately 1 liter of urine, and the resident stating, "It's bothering me." The anchoring device was present but not adhered to the resident's body, and the insertion site was open to air with no dressing. A small shallow pink, moist ulcer was observed around the stoma with some redness to the surrounding area, and the waistband of the resident's sweatpants appeared to rest directly over the catheter insertion site. An LPN present during the observation stated the site should be covered, the collection bag should be emptied and picked up off the floor, and confirmed the anchoring device was not attached correctly. The resident's EHR showed admission with neuromuscular dysfunction of the bladder and a supra-pubic catheter, and a physician order from 2/2/26 directed staff to ensure the anchor was in place. The annual MDS indicated a supra-pubic catheter and triggered urinary incontinence/indwelling catheter as a care area assessment, but there was no urinary or catheter care plan, and the UTI care plan contained no catheter care interventions. The DON later stated there were orders to cleanse and dress the site every day and as needed, and that care plans were in place now.
Pureed Vegetables Served at Improper Consistency
Penalty
Summary
The facility failed to prepare vegetables to the proper food consistency for four residents receiving pureed-textured meals. During lunch service observation, the steam table was set with pans of food ready to be served, but the pan of prepared pureed green beans was sitting in a pan of water on the hot stove because there was not enough space on the steam table. When the green beans were checked, they appeared lumpy, and both the Dietary Manager and the two State Surveyors tasted a sample and agreed the green beans contained lumps. The Dietary Manager stated the green beans needed to be smoother, and the Head [NAME] S told staff on the tray line to set aside the meal tickets for residents on pureed diets while the green beans were being smoothed out in the blender. When the Registered Dietitian was asked about pureed food consistency, they stated it should be smooth like pudding.
Failure to Protect a Resident From Chemical Spray Abuse by Housekeeping Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and mental abuse by housekeeping staff. Video evidence from the facility showed the Housekeeping Manager spraying a bottle identified by the Nursing Home Administrator as Clorox bleach cleaner directly at the resident’s face in a sixth-floor hallway, with approximately five sprays observed. During this incident, a housekeeper was seen holding the resident’s wheelchair in place while the Housekeeping Manager sprayed the chemical. A CNA who witnessed the event reported that the Housekeeping Manager stated, "I'm gonna fuck him up" and then sprayed more bleach cleaner into the resident’s face, and the CNA recognized the product as bleach spray by its smell. The resident involved had diagnoses including schizoaffective disorder, dementia, acquired absence of the left leg below the knee, and asthma, and was wheelchair-bound with moderate cognitive impairment. Prior documentation indicated the resident had adequate vision, did not wear corrective lenses, and had no history of eye disease or corneal haze, aside from dry eyes. A practitioner exam earlier in the month documented normal eye findings with white conjunctiva and non-icteric sclera, and the DON confirmed there were no prior eye consultations or documented eye conditions beyond dry eyes. Following the incident, the resident reported that staff sprayed a chemical in his eyes, that his right eye remained painful and "messed up," and that he had been treated at a hospital. Hospital and ophthalmology records documented evaluation for eye pain and chemical exposure of the eyes, with findings of significant epithelial irritation, corneal haze that was improving, mild conjunctival redness, and periorbital puffiness. The ophthalmology consultation diagnosed chemical exposure of the eye with chemical damage to the front of the eyes, noted as improving, and specified there was no limbal ischemia. These findings were directly linked in the medical record to the allegation of chemical exposure during a confrontation between the resident and a facility staff member.
CNA Exploits Resident's Debit Card for Unauthorized Purchases
Penalty
Summary
A certified nursing assistant (CNA) used a resident's debit card to make unauthorized purchases totaling $1,900, constituting exploitation and misappropriation of resident property. The incident was discovered when the facility attempted to process a payment with the resident's debit card, which was declined. The resident, who was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 12 out of 15, confirmed the incident during an interview. The CNA admitted to obtaining the debit card number and making the purchases, later acknowledging the violation of facility rules and resigning. The facility's policy prohibits abuse, neglect, exploitation, and misappropriation of resident property, defining exploitation as taking advantage of a resident for personal gain. Despite this policy, the CNA was able to access and use the resident's financial information. The resident had a medical history including hypertension, fractures, protein malnutrition, and physical disability, and was admitted to the facility with these diagnoses. The incident resulted in a significant financial loss for the resident, with only partial recovery of the funds at the time of the report.
Deficient Sanitation and Equipment Maintenance in Food Service Area
Penalty
Summary
Surveyors observed multiple failures in the facility's food service area related to cleaning and maintenance of equipment, directly impacting the sanitary conditions for 107 residents who consume food products. During a comprehensive tour, the sanitizer basin of the 3-compartment sink was found to have a quaternary ammonia concentration exceeding 500 parts-per-million (PPM), which is above the recommended level according to the manufacturer's instructions and the FDA Food Code. The Dietary Manager acknowledged the issue and indicated the need for vendor intervention to adjust the chemical dispensing assembly. Additional observations included the interior stainless steel retention plate of the ice machine, which was heavily stained and corroded with rust scale deposits. The can opener assembly and mounting plate bracket were found to be heavily soiled with encrusted food residue, and the cutting blade was blackened with excessive buildup. The coffee machine's interior and exterior surfaces were also soiled with accumulated and encrusted food residue. Furthermore, the commercial microwave oven's exterior door handle was cracked, broken, and could be rotated completely, indicating a lack of proper maintenance. Record reviews of facility policies revealed that there are established procedures for sanitation inspections and manual warewashing, which require all food service areas and equipment to be kept clean, sanitary, and in good repair. However, interviews with the Dietary Manager indicated uncertainty regarding the specific policies and procedures for cleaning and maintaining food service equipment, suggesting a gap between policy and practice. No information was provided about any residents' medical history or condition at the time of the deficiency.
Failure to Maintain Sanitary and Functional Environment Due to Inadequate Cleaning and Drain Maintenance
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. Observations revealed that six out of nine PTAC unit filters in the first floor Main Dining Room were heavily soiled with accumulated and encrusted dust and dirt deposits, and the cabinet surfaces of these units were also dirty. Additionally, the flooring surface in the same dining area was found to be soiled with dust, dirt, and food residue. Staffing interviews indicated that the housekeeping department had ten housekeepers in total, with only one housekeeper assigned to the second shift, and three housekeepers covering call-offs and days off. Further investigation into the facility's maintenance practices uncovered ongoing issues with the food production kitchen floor drain, which was reported to flood randomly, sometimes daily or weekly. The Corporate Life Safety and Maintenance/Environmental Director confirmed a history of wastewater issues dating back nine years and described a reactive approach to drain maintenance, including snaking drains as needed and periodic cleaning of grease traps and wastewater lines. Review of the facility's policy on sewage and waste disposal indicated a requirement for maintaining free-running sewer lines and outlined steps for addressing blockages, but the observed conditions and staff interviews demonstrated lapses in effective implementation.
Failure to Document and Communicate Transfer/Discharge Information
Penalty
Summary
The facility failed to document complete transfer and discharge information for one resident who was reviewed for the transfer/discharge process. The resident, who had multiple diagnoses including paraplegia and a recent surgical repair of a fractured right femur, was admitted to the facility and later transferred to another long-term care facility after returning from the hospital. The electronic health record contained a progress note indicating the transfer, but there was no transfer form to the hospital, no discharge plan, summary note, or progress notes to indicate that instructions had been given to the receiving hospital or LTC facility regarding the resident's ongoing healthcare needs. Interviews with the DON and NHA confirmed that there was no transfer or discharge summary for the resident, and that the required information had not been provided to the receiving healthcare providers. The facility's own policies require that transfer/discharge notices and discharge planning documentation be completed and communicated to the resident, their representative, and the receiving provider, but these steps were not documented in this case.
Failure to Reconcile Controlled Drugs in Back-Up Box
Penalty
Summary
The facility failed to maintain a proper record of receipt, disposition, or reconciliation of controlled drugs in its back-up box, which is a secured storage unit for controlled drugs. During an observation, it was noted that the narcotic drawer lacked a plastic lock, indicating it had been opened after the pharmacy delivered a fully restocked narcotic supply. There was no documentation available to indicate when the pharmacy last delivered the back-up box or when narcotics had been removed. A sheet of paper with multiple undated entries showed that narcotics had been removed, with the last dated entry being 31 days prior. Upon inspection, discrepancies were found in the number of tablets present compared to what should have been available according to the dispensing sheets. The Director of Nursing (DON) was unable to explain the facility's process for narcotic reconciliation or the use of plastic locks on the narcotic drawer. The facility's pharmacist confirmed that the pharmacy delivers a fully stocked back-up box weekly with a numbered plastic lock. However, discrepancies were noted in the number of narcotics present versus what was recorded on the dispensing sheets. The pharmacist could not account for these discrepancies and mentioned that they only have the dispensing forms faxed by the nursing staff. The facility's Pharmacy Services policy requires a system of medication records for accurate reconciliation and accounting for all controlled medications, but this was not adhered to, leading to potential drug diversion and unavailability of controlled drugs for residents as prescribed.
Delayed Response to Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure timely action and communication regarding Medication Regimen Review (MRR) recommendations for two residents, resulting in the continuation of unnecessary medications. For one resident, the pharmacist recommended reducing or discontinuing sliding scale insulin due to its inefficiency and potential risks, as per AMDA guidelines and the American Geriatric Society's Beers Criteria. Despite the pharmacist's recommendation on multiple occasions, the physician did not review the recommendation until several months later, leading to a delay in addressing the medication regimen. For another resident, the pharmacist recommended discontinuing or specifying the duration for the PRN use of Xanax, in accordance with federal guidelines. However, the physician did not respond to these recommendations over two consecutive months. The Director of Nursing acknowledged the delay in physician response, noting that the expectation is for irregularity reports to be addressed within 30 days. This lack of timely communication and action between the pharmacist and physician contributed to the deficiency in medication management for the residents involved.
Medication Error in Antibiotic Eye Drop Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when only two doses of an antibiotic eye solution were administered out of the 56 doses prescribed. This resulted in the potential for prolonged signs and symptoms of a right eye infection. The resident, who had a history of a stroke, dysphagia, and a ruptured right eye, was observed with a sunken right eye and dried yellow crust on the eyelids. The resident's family member reported that the right eye infection had improved with less drainage than before. The resident's Electronic Health Record indicated a physician's order for erythromycin ophthalmic solution to be administered every four hours, but the Medication Administration Record showed that the resident only received the medication twice on one day. The Nurse Practitioner confirmed that the order was for a 14-day course of the antibiotic eye drops, but the orders were transcribed incorrectly on the MAR, leading to the resident not receiving the full course of treatment. The Director of Nursing acknowledged the transcription error, stating that the resident should have received the eye drops for 14 days.
Failure in Antibiotic Stewardship Program Monitoring
Penalty
Summary
The facility failed to maintain a complete and accurate Antibiotic Stewardship Program, which resulted in a deficiency related to the monitoring and administration of antibiotics for a resident with an eye infection. The Infection Control Nurse (IFC) was unaware of the resident's prescription for Erythromycin ophthalmic solution for bacterial conjunctivitis, as the resident was not listed on the infection report log for November 2024. This oversight occurred despite the facility's protocol to document residents prescribed antibiotics on the infection report log for monitoring. The IFC nurse acknowledged that the resident's antibiotic usage was not documented or monitored, leading to an administration error. The resident's Electronic Health Record (EHR) indicated that they were prescribed Erythromycin ophthalmic solution for 14 days, but the Medication Administration Record (MAR) showed that the resident only received two doses on the first day. The Nurse Practitioner clarified that the order was for the eye drops to be administered four times a day for 14 days, but this was not followed. The IFC nurse admitted to not being notified of the prescription and recognized that if the antibiotic had been included in the infection report, the administration error might have been avoided. The facility's Infection Prevention and Control Program outlines the need for an antibiotic stewardship program, but the lack of documentation and monitoring led to this deficiency.
Deficiency in Influenza Vaccination Program
Penalty
Summary
The facility failed to consistently screen, educate, offer, and administer influenza vaccines to five residents, resulting in a deficiency. Resident R57 consented to receive the influenza vaccine, but there was no documentation in the Electronic Health Record (EHR) to confirm the administration of the vaccine. The Infection Control Nurse (IFC) D and the Corporate Clinical Director, RN Q, acknowledged the absence of evidence supporting the administration of the vaccine, despite the facility having the vaccine available. For residents R4, R9, R40, and R52, the facility did not complete the necessary documentation to indicate whether these residents were screened, educated, or offered the influenza vaccine. The consent forms for these residents were incomplete, undated, and lacked necessary signatures. In particular, R9 and R52, who had legal guardians, did not have documentation showing that their guardians were contacted or educated about the vaccine. RN Q acknowledged the invalidity of these incomplete forms. The facility's Infection Prevention and Control Program policy states that residents should be offered the influenza vaccine annually and provided with education regarding the benefits and potential side effects. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and incomplete consent forms for the residents reviewed. This failure to follow established procedures resulted in a deficiency in the facility's vaccination program.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a clean and well-repaired environment on the third floor, affecting 25 residents. Observations revealed cracked and chipped floor tiles, broken resident equipment, and a persistent malodorous smell. Additional issues included detached aluminum tape on air conditioning units, visible dirt and food particles on floors, broken hand sanitizer dispensers, missing window blind slots, and rusted bed frames. Interviews with the Housekeeping/Laundry Director and Environmental Director indicated that while there was a cleaning schedule, there was no evidence of monitoring by management, and the third floor was the last to be renovated with no known timeframe. On the fifth and second floors, the facility also failed to maintain cleanliness and repair, increasing the likelihood of cross-contamination and bacterial harborage. Observations included non-working lights in an elevator, a strong urine odor with stained baseboards, dingy and scratched hallway paint, and damaged wheelchairs for two residents. The Director of Maintenance and Regional Director of Maintenance noted these issues during a tour, and the Nursing Home Administrator acknowledged that cleaning and maintenance were ongoing processes, but the maintenance checklist lacked specific entries related to these concerns.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards of medication administration in three instances. Firstly, an LPN did not prime an insulin pen before administering 35 units of Lantus insulin to a resident, which is against the manufacturer's guidelines and the facility's policy. Priming is necessary to remove air bubbles from the insulin reservoir to ensure the correct dosage is delivered. The LPN was unaware of the priming process, indicating a lack of training or understanding of the procedure. Secondly, the same LPN administered seven medications through a PEG tube to another resident without individually crushing and flushing each medication, contrary to the facility's policy. This practice can affect the efficacy and safety of the medications. Lastly, a transcription error was identified in the medication administration record for an anti-hypertensive medication, Metoprolol Tartrate, prescribed to the same resident. The error involved a misrecorded dosage, which was not clarified until 25 administrations later, despite the resident receiving the correct dosage. The Director of Nursing acknowledged the transcription error and the delay in its correction.
Failure to Provide Adequate Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide adequate hair care and grooming for three residents, resulting in unmet hygiene needs and emotional distress. One resident, who was receiving hospice care, was observed with unkempt hair that was matted and contained lint. The resident's family expressed concern about the lack of grooming, noting that the resident's hair had not been combed or washed for some time. The resident was severely impaired in cognitive skills and required assistance with activities of daily living (ADLs). Another resident was observed with tangled hair in a knotted ponytail, secured with a broken rubber band. This resident, who had contracted hands and required assistance with feeding, confirmed that staff did not comb or brush her hair. The resident was moderately impaired in cognitive skills and required supervision for decision-making, as well as assistance with ADLs due to various medical conditions. A third resident, who was legally blind, was observed with a visible beard and soiled clothing. This resident required supervision and assistance with ADLs due to impaired vision and mobility. Interviews with staff revealed confusion about who was responsible for grooming, with some believing it was the responsibility of the hospice company or the Activity Department. However, the Activity Director confirmed that no requests for grooming services had been made for the residents on the third floor.
Inadequate Supra-Pubic Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate supra-pubic catheter care for a resident, resulting in discomfort at the insertion site and the potential for catheter dislodgment and urinary tract infection. Observations revealed that the catheter tubing was taut and not properly secured, with the collection bag often positioned at the level of the bladder rather than below it. The resident expressed discomfort and noted that the catheter had been dislodged before, requiring hospital intervention. The insertion site was observed to be slightly reddened with dried yellow crust, and there was no dressing or anchoring device in place. Interviews with staff indicated a lack of consistent catheter care, with a CNA deferring responsibility to the nurse and an LPN acknowledging the need for an anchoring device but failing to recall specific care actions taken. The resident's electronic health record and care plan outlined specific catheter care instructions, including securing the catheter and positioning the collection bag below the bladder, which were not consistently followed. A previous incident of catheter dislodgment was documented, highlighting ongoing issues with catheter management.
Failure to Justify PRN Antianxiety Medication Use
Penalty
Summary
The facility failed to justify the use of a PRN antianxiety medication, Xanax, for a resident with a history of cerebral infarction, major depressive disorder, and adjustment disorder with mixed anxiety and depressed mood. The resident, who had intact cognition, was prescribed Xanax with an open-ended end date, and there was no documentation of a 14-day stop date or a gradual dose reduction attempt in the Electronic Health Record (EHR). The care plan identified the resident as being at risk for adverse consequences related to psychotropic drug use, but there was no medical justification for continuing the Xanax past 14 days. Interviews with facility staff revealed that the visiting psychiatry group typically monitors psychotropic medications, but in this case, the oversight was missed. The Social Worker confirmed the lack of a gradual dose reduction attempt or rationale for continued PRN use past 14 days. The Director of Nursing acknowledged that the physician did not respond to the pharmacist's irregularity report and failed to document justification for the continued use of Xanax. The expectation was for the visiting psychiatry group to monitor these medications, but they did not address the resident's Xanax prescription.
Lack of Coordination in Hospice Services Documentation
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in a lack of coordination of comprehensive care. The resident, who was admitted with multiple diagnoses including acute respiratory disease and severe cognitive impairment, was under hospice care. However, the facility did not maintain adequate records of hospice services, as evidenced by the absence of nursing notes or visitations in the hospice logbook. This lack of documentation hindered the facility's ability to coordinate and communicate effectively with hospice staff. During the survey, it was discovered that the hospice notebook only contained a schedule of visitations from the social worker, chaplain, and nurse aide, but no notes from the nurse. The Corporate Consultant later confirmed that the hospice company was contacted to provide the missing nurses' notes, which should have been included in the resident's electronic medical record after each visit. The Director of Nursing acknowledged the issue, indicating that staff should have been communicating with hospice staff on-site, but was unable to explain how coordination was possible without access to the nurse's documentation.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents, resulting in potential transmission of infectious organisms. For one resident, staff members, including a CNA, RN, and Wound Care Coordinator, were observed providing care without wearing PPE, despite the resident having a stage IV pressure ulcer and a history of sepsis and bacteriuria. Interviews revealed that staff were aware of enhanced barrier precautions but did not follow them, and there was no signage on the resident's door to indicate the need for PPE. The Director of Nursing acknowledged the need for retraining, and the Nursing Home Administrator confirmed that staff understood the precautions but did not implement them. For another resident with a PEG tube and recent diagnosis of bacterial conjunctivitis, CNAs and an LPN were observed providing care without wearing gowns, despite a sign in the hallway indicating the need for enhanced barrier precautions. The CNAs and LPN were unaware of the specific PPE requirements for residents on enhanced barrier precautions. The Director of Nursing stated that staff had been educated on proper PPE use, but the observations indicated a lack of adherence to the facility's policy on enhanced barrier precautions.
Call Light System Malfunction on Third Floor
Penalty
Summary
The facility failed to ensure that the call light system was properly functioning on one of its units, specifically the third floor, which resulted in a potential delay in responding to residents' care needs. During an observation, it was noted that residents were using assorted bells in their rooms instead of the standard call light system. One resident, who was alert and oriented, was unsure of the bell's location and mentioned going to the nursing station when in need of assistance. Another resident confirmed that the bells were provided because the call lights were not working, and sometimes the nurses could not hear the bells if they were down the hall. The Director of Maintenance (DM) reported that the issue began after an incident where an irate resident damaged the main box at the nursing station, leading to the malfunction of the call light system. The residents had been using the bells for approximately three weeks. Although the facility had obtained an undated estimated invoice for updating the nurse's call system on the third floor, there was no evidence of a signed contract or a plan for initiating or completing the repairs. The Administrator mentioned that the third floor was the last to be renovated, but no additional information regarding the timeline for the renovation was provided.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to review or revise the care plans for two residents following multiple falls, which is a deficiency in their fall prevention program. Resident R701, who was admitted with a fracture of the lower end of the right tibia and a pressure ulcer of the left heel, experienced falls on four separate occasions. Despite these incidents, the care plan interventions for R701 had not been updated since November 8, 2023, indicating a lack of timely response to the resident's changing needs. R701 also had impaired cognition and required assistance with bed mobility and transfers, which were not adequately addressed in the care plan updates. Similarly, Resident R704, who was admitted with cerebral infarction and epilepsy, experienced a fall on August 28, 2024. The review revealed that R704 had two fall care plans, one of which had not been updated since July 13, 2021, and the other lacked interventions to minimize the risk of additional falls. R704 also had impaired cognition and required assistance with bed mobility and transfers. The Director of Nursing acknowledged that the care plan should be updated with an intervention when a fall occurs, as per the facility's Fall Prevention Program policy, but this was not done for these residents.
Failure to Implement Fall Prevention Intervention
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as R702, who was at risk for falls. On the specified date, R702 was observed alone in their room, seated in a wheelchair, with a fall mat placed beside the bed. The resident's medical record indicated diagnoses of dysphagia and a brain disorder, with a cognitive impairment score of 2/15 on the Brief Interview for Mental Status, requiring assistance with bed mobility and transfers. The fall care plan, initiated on June 10, 2024, included the use of a concave mattress as an intervention. However, upon inspection, the Director of Nursing confirmed that R702's mattress was a regular one, not concave, as required by the care plan. The DON, new to the role, was unaware of the discrepancy and acknowledged the need for the correct mattress.
Failure to Monitor Resident Weights and Nutritional Status
Penalty
Summary
The facility failed to implement interventions to obtain resident weights for two residents who refused to be weighed, resulting in significant weight changes going undetected. Resident 902, diagnosed with Alzheimer's disease, had not been weighed since March 6, 2024, and was found to have lost 29.7 lbs (16.3% weight loss) over two months. The resident's dietary progress notes and care plans had not been updated or revised since early 2023, and no nutritional assessments had been completed since August 3, 2023. The facility did not document any nutritional interventions or assessments for Resident 902 from January 2024 to May 14, 2024, despite the significant weight loss observed by a family member and confirmed by staff on May 15, 2024. Resident 903, who is morbidly obese and a dialysis patient, had refused to be weighed multiple times, with the last recorded weight on February 17, 2024, showing 266.1 lbs. The resident's weight was documented as 305 lbs on May 13, 2024, indicating a 14.6% weight gain. Despite the availability of weight records from the dialysis center, the facility did not use this information to monitor the resident's weight. Nutritional assessments for Resident 903 were incomplete, missing critical information such as current weight, BMI, and weight status. The dietary care plans for Resident 903 had not been reviewed or revised since February 28, 2024. Interviews with the Director of Nursing, Registered Dietician B, and Corporate Registered Dietician C revealed that the facility's policy required monthly weight monitoring and nutritional assessments on admission, quarterly, and with significant changes. However, these protocols were not followed for Residents 902 and 903. The facility failed to notify physicians or the interdisciplinary team about the residents' refusal to be weighed, and no alternative assessment tools were used to evaluate their nutritional status. The lack of proper documentation and follow-up led to significant weight changes in both residents going unaddressed.
Failure to Prevent Fall and Provide Adequate Supervision
Penalty
Summary
The facility failed to implement necessary interventions and provide adequate staffing to prevent falls, resulting in a serious incident involving a resident identified as R921. R921, a hospice patient with a history of stroke and right-side weakness, was found unresponsive on the floor with a pool of blood around the head. Despite being identified as 'not at risk' for falls in a previous assessment, the resident's care plan did not address fall prevention, and a floor mat intervention was not in place at the time of the incident. The incident occurred during a period of staffing shortages, as reported by LPN A, who noted that the facility was short-staffed on the day of the incident. LPN B, who worked the night shift, was responsible for two floors with only one aide, which was below the usual staffing level. This staffing issue contributed to inadequate supervision, as LPN B had to manage multiple responsibilities, including attending to a wanderer and problematic call lights, which may have limited the ability to monitor R921 effectively. The facility's fall prevention policy was not adequately followed, as evidenced by the lack of a fall risk indicator on R921's care plan and the absence of a floor mat. The policy required routine rounding and specific interventions for residents at risk of falls, which were not implemented for R921. The lack of adherence to the fall prevention program and insufficient staffing levels were significant factors leading to the incident, highlighting deficiencies in the facility's ability to provide a safe environment for its residents.
Non-Functional Call System in Resident Rooms and Shower Areas
Penalty
Summary
The facility failed to provide a functional call system for residents, particularly affecting those on the 2nd floor and in rooms 215, 307, and 312, as well as the shower rooms on the 2nd, 3rd, and 4th floors. During facility rounds, it was observed that there was no call light panel at the nurse's station to notify staff of resident needs. A nurse on duty was unaware of the missing panel, and call lights in specific rooms were found to be non-functional. Two residents reported their call lights had been non-operational for over two weeks, while another resident mentioned their call light had not worked for nearly six months, forcing them to call out for help or go to the doorway to seek assistance. Further environmental rounds with a corporate life safety support staff member revealed that the call lights in the shower rooms were not functional due to missing pull cords and non-functional alerts. These issues were confirmed during testing. Despite a request for call light audit logs from December 2023 to April 2024, the facility failed to provide them. The staff member responsible for life safety support admitted to not checking the maintenance logs during monthly rounds and acknowledged that unresolved maintenance concerns should have been addressed promptly. An interview with the facility administrator confirmed awareness of the call light issues and the lack of maintenance follow-up. The facility's policy on call lights emphasized the importance of ensuring accessibility and timely response, yet the policy was not effectively implemented. The absence of functional call lights and the failure to maintain audit logs indicate a significant oversight in ensuring resident safety and communication needs.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, staff, and the public, as evidenced by multiple deficiencies observed during a survey. The surveyor noted missing handrails in the elevator, malfunctioning elevator lights, and a delay in the elevator door closing, which had been ongoing for months. Additionally, there were widespread issues with gnats in various rooms and common areas, missing insulation around PTAC units, non-functional electrical outlets, broken blinds, and missing clocks in resident rooms. These deficiencies affected the living conditions and satisfaction of all 97 residents. Further observations revealed significant maintenance issues, including broken bedside tables, missing or broken tiles in shower rooms, and non-functional shower facilities on the 5th floor, forcing staff to use other floors for resident showers. The maintenance logs on multiple floors showed numerous unresolved entries, some dating back several months, indicating a lack of timely response to maintenance concerns. These unresolved issues included non-working heaters, leaking ceilings, sparking AC units, and broken blinds, among others. Interviews with staff, including a corporate life safety support staff member and the facility administrator, highlighted a breakdown in the process for notifying and resolving maintenance concerns. The maintenance personnel were expected to conduct daily rounds and address issues promptly, but this was not happening effectively. The facility's document titled 'Safe and Home Like Environment' outlined the expectations for maintaining a safe and comfortable environment, but the observed conditions fell short of these standards.
Inconsistent Resident Council Meetings and Lack of Documentation
Penalty
Summary
The facility failed to consistently assist the Resident Council in organizing and conducting monthly meetings, as well as in promptly addressing and resolving concerns raised by the council. Multiple complaints were received by the State Agency regarding issues such as long call light wait times and concerns with the facility's physical environment. Upon request, the facility administrator and DON were unable to provide resident council meeting minutes or follow-up documentation from November 2023 to April 2024. The Activities Director, who was new to the role, reported that they had scheduled future meetings but had no records for the requested period. An interview with the Resident Council president revealed that meetings were inconsistent, and there were insufficient chairs for representatives, with some sitting on milk crates. The facility's policy supports the rights of residents to organize and participate in resident groups, with the Resident Council meeting at least quarterly. However, the facility did not adhere to this policy, as evidenced by the lack of meeting minutes and follow-up documentation. The administrator acknowledged the absence of records and mentioned a new team and plan in place, but this did not address the deficiency during the survey period.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to promptly and thoroughly investigate allegations of abuse and neglect, including an injury of unknown origin, for several residents. Specifically, a hospice patient was found unresponsive on the floor with a serious head injury, and the facility did not conduct a timely investigation. The Facility Reported Incident (FRI) was submitted late, and the investigation report was incomplete, lacking staff interviews and record reviews. The Director of Nursing (DON) was absent during the initial days following the incident, and no other nurse manager initiated an investigation in their absence. Additionally, the facility did not comply with its policy or regulatory requirements for other incidents involving allegations of abuse between residents. The facility's policy mandates immediate investigation and reporting of such incidents, but the investigations were delayed, and reports were submitted late to the State Agency. The Nursing Home Administrator acknowledged these deficiencies, indicating a failure to adhere to the facility's procedures for handling allegations of abuse and neglect.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to follow up on grievances expressed by two residents, resulting in frustration and ongoing communication concerns. One resident, who was admitted with diagnoses including major depressive disorder and heart failure, reported missing personal belongings that were taken to the laundry. Despite speaking with several staff members over two weeks, the resident received no follow-up, leading to frustration. Another long-term resident, with conditions such as heart failure and diabetic neuropathy, expressed concerns about call light wait times, staff not checking blood pressure before administering medications, and being taken to another floor for showers. This resident also reported making staff aware of these concerns. The facility's grievance policy states that grievances should be resolved within five days, and the administrator acknowledged the need to review and follow the facility's policy. However, the facility did not provide grievance forms or evidence of follow-up for the two residents. The administrator, who was new to the facility, mentioned maintaining resolved grievance forms in a binder for review during Quality Assurance and Process Improvement meetings. The facility's policy emphasizes the right of residents and family members to voice grievances without fear of reprisal and outlines the responsibilities of the Grievance Official in overseeing the grievance process.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an injury of unknown origin involving a hospice patient, identified as R921, to the Nursing Home Administrator and the State Agency. The incident occurred on 4/10/24 when R921 was found unresponsive on the floor with bleeding around the head and no vital signs. Despite the serious nature of the injury, the Facility Reported Incident was not submitted to the State Agency until 4/12/24, two days after the occurrence. The Nursing Home Administrator acknowledged the delay in reporting and attributed it to not being made aware of the full details until later. The facility's policy on 'Abuse, Neglect, and Exploitation' requires that all alleged violations involving serious bodily injury be reported immediately, but not later than two hours after the allegation is made. In this case, the policy was not followed, as the report was delayed beyond the specified timeframe. The Nursing Home Administrator admitted that the staff should have reported the injury immediately as an injury of unknown source, indicating a lapse in adherence to the facility's reporting procedures.
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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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